All right, we’re going to
discuss prenatal care in
this module and we’re going
to start with a case.
We have a 30-year-old woman here
for her first prenatal visit.
Her estimated gestational age
is eight weeks, pretty common.
So you should recommend all the
following procedures to her except --
so this is an except question,
which one should we
not do at this time when
she’s eight weeks pregnant?
initiation of folic
measurement of her
or testing for hepatitis B surface
antigen and rubella immunity.
Which one should we
not do on that list?
Measurement of fundal
height, and you say,
“Well, wait. Why should we not
measure her fundal height?”
Because she’s only eight weeks.
So usually, we initiate measurement
of the fundal height at 20 weeks.
You’re not going to be able
to get much until that time.
Let’s look at the schedule for
routine prenatal care first.
So generally, I know
this can change based on
where you happen to be
practicing on the planet.
In the United States, for the
average-risk patient, again, this
is not high-risk care or somebody
turns into a high-risk patient,
it’s monthly through 28
weeks of gestational age,
then twice a month
between 28 and 36 weeks,
and then from 36 weeks until
delivery every single week.
That’s the typical schedule.
And as I mentioned, that’s
for normal healthy patients.
Patients with diabetes
or other, you know, twin
pregnancies, they’re going
to be seen more often.
So just to provide some
landmarks over these visits,
the first visit includes a
pelvic examination complete.
Also, you’re going to initiate
folic acid supplementation.
The recommendation is at
least 400 micrograms daily.
Usually, we’re recommending 1
milligram daily, so 1000 micrograms.
Body weight and blood
pressure checks all visits.
You should be able to auscultate
the fetal heart tones
with a Doppler ultrasonography at
gestational age 10 to 12 weeks.
Now at 20 weeks that I
mentioned that’s when
you’re going to start
checking fundal height.
And at 36 weeks you’re going
to check the fetal lie.
Now, that’s not all we do.
We’ll fill in some laboratory work and
some other recommendations along the line.
But in terms of clinical examinations
those are what you’re going to do.
What may not want to do?
Routine urinalysis is now not favored at
all visits, really has a poor sensitivity
for diagnosing common disorders such as
gestational diabetes and preeclampsia.
Better evaluated in other
ways, through checking your
blood pressure you’re doing
a glucose tolerance test.
And whereas before it was
recommended that all women
undergo cervical cancer
screening during pregnancy.
That’s to be done just if they
happen to fall into their usually
every three-year period where the
Pap test is actually required.
If they had it done a year ago and
it was normal, no need to repeat it.
What about labs at
the initial visit?
Doing a CBC and HIV test,
a hepatitis B surface
blood type and Rh screen looking
for future incompatibility,
rubella immune status, a syphilis test,
and gonorrhea and chlamydia
testing, and that’s it.
Many women have a question
about their diet in
pregnancy, what’s safe to
eat, what’s unsafe to eat.
Most artificial sweeteners are probably
safe, and again, everything in
moderation, and especially if it’s not
overused, it’s very likely to be safe.
But saccharine should be
avoided during pregnancy.
Moderate caffeine intake is also probably
safe, so one to two cups of coffee per day.
Extreme intake is not
going to be healthy,
as is unpasteurized foods and deli
meats because of the risk of Listeria
associated with those and the potentially
devastating effects on pregnancy.
Therefore, avoid those
things during pregnancy.
Fish, it’s possible to eat fish,
but they do -- all sea food
contains some degree of mercury,
and so therefore, the recommendation is
a max of 12 ounces of fish per week.
But certain types of fish, where there’s
a high concentration of mercury,
swordfish and shark should
be absolutely avoided,
also, raw fish because of the potential
for contamination and infection.
And this in honor of one of my favorite
colleagues, who like to tell her patients that
just because you’re
pregnant you can’t go
crazy and consume five
banana splits per day.
The extra calories that are generally
required during pregnancy are about
300 to 400 per day, or three pieces
of fruit, or just one candy bar.
So the extra four sundaes probably aren’t
going to fly and they’ll just contribute to
obesity and problems like gestational
diabetes and pregnancy-induced hypertension.
And so let’s talk about weight
gain goals during pregnancy.
For normal weight individuals, 11
to 15 kilograms or 25 to 35 pounds,
for overweight individuals they don’t need
to gain as much weight during pregnancy
and they certainly this can lead to higher
risk after pregnancy if they gain an undue
amount of weight in
pregnancy, more likely to
hypertension and diabetes.
So a lower goal, and even a lower
goal for women who become pregnant
when they’re obese, only 11 to
20 pounds or under 10 kilos.
How about some other important
pieces of advice during pregnancy,
these are common questions that
patients are going to have.
Is it safe for me to
go on an airplane?
It actually is.
It’s safe for the
fetus up to 36 weeks,
but do remember that for
long plane flights,
women who are pregnant are at
a higher risk for thrombosis.
So that’s something they should
understand before committing
to particularly a plane
flight of four or more hours.
Patients will ask you,
“Can I exercise?”
Absolutely, particularly if
they’ve been exercising,
And so moderate exercise up to 30
minutes on most days of the week is
helpful, maintains a healthy weight
and is healthy for mommy and baby.
Things to avoid:
hair treatments, hot tubs and saunas
during the first trimester in particular.
Those can potentially do
damage to your pregnancy.
And for pain, which is
really common during
is the safest over all.
For common cases of nausea and
vomiting during the first trimester,
vitamin B6 and some dietary
patterns with having crackers
available and eating first
thing on waking up,
that can be helpful, as well,
and that works for most women
and that condition does usually
pass on after a few weeks.
How about ultrasonography,
when should it be recommended?
If the dates are unclear on
the pregnancy, that’s an
indication for immediate
referral for a sonogram.
The real evidence for routine
ultrasonography, it does
reduce the chance of having a missed
multiple gestations, where you
think there’s a singleton pregnancy,
it turns out to be twins or more.
Also reduces the risk for a post-dates
pregnancy, but not every study of routine
ultrasonography have actually demonstrated
any benefit during pregnancy.
And again, it’s probably worth
mentioning now that pregnancy is
not like many other things we’ve
talked about, a disease state.
This is a natural process
that’s part of the life cycle.
That said, in the United
States, most women are
offered a single ultrasound
at 18 to 20 weeks.
That’s the best time for
doing a fetal anatomy survey
and it also fits in in
screening for aneuploidy.
Let’s talk about that.
So standard in the United States
now is a screening system that
includes both the first and second
trimester testing, and it’s mixed.
It’s not just about lab any more,
it’s about ultrasound finding,
and it’s added in some maternal
factors such as their age.
It demonstrates a fair sensitivity
and a strong specificity.
And overall still has a low
positive predictive value,
but it is good as a screening
tool for referring women who
appear to be at increased risk
for further testing, such as:
Amniocentesis is really
the next stage when
there is a risk detected
for fetal aneuploidy.
A chorio villus sampling
is another option.
The rates of -- amniocentesis
is a specialized procedure.
The risk of an abortion with
amniocentesis is about 0.5% or so.
So it’s very rare to have a serious
complication, but it is something
that needs to be explained to
patients before the procedure.
Another option that has emerged is
actually drawing fetal cells from
the maternal circulation and then
doing DNA testing on them directly.
That provides a more
accurate means of screening
for aneuploidy, but it’s
also pretty expensive.
Other testing and procedures that
are routine during pregnancy,
so this is really again, this is
for your average-risk patient.
One-hour glucose tolerance
testing at age 24 to 28 weeks.
Among women who are obese
when they become pregnant,
maybe they should be screened
right away for diabetes,
also, women with a history of previous
gestational diabetes get screened right away.
But for other average-risk women they
can wait till the second trimester.
Screening for group B
strep at 35 to 37 weeks
with initiation of precautions
during labor with IV antibiotics
to prevent sepsis
in the newborn.
Repeating urinalysis for bacteria
between 11 and 16 weeks of gestation.
So I would recommend the influenza
vaccine to every pregnant women,
they are at higher risk for
complications of influenza.
A recent study showed that influenza
vaccination during pregnancy,
during the first trimester specifically,
may be associated with a higher risk of
conduct problems and behavioral
problems among children,
and so therefore, it’s okay to delay
till the second or third trimester
because there’s a broad window for
applying the influenza vaccine.
Tdap should be applied between
27 and 36 weeks of gestation.
And then finally, women who are pregnant
should not receive the rubella vaccine,
but they can be seen at the
post-partum visit and given
the rubella vaccine at that
time during lactation.
So those are some of the guidelines
regarding prenatal screening.
A lot of information in there,
a lot of dates to follow.
But when you do so, you’re
really providing the best care
for your patients in keeping
both mom and baby healthy.