Prenatal Care

00:00 All right, we’re going to discuss prenatal care in this module and we’re going to start with a case.

00:06 We have a 30-year-old woman here for her first prenatal visit.

00:10 Her estimated gestational age is eight weeks, pretty common.

00:15 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? HIV testing, initiation of folic acid supplementation, measurement of her fundal height, or testing for hepatitis B surface antigen and rubella immunity.

00:35 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.

00:46 So usually, we initiate measurement of the fundal height at 20 weeks.

00:51 You’re not going to be able to get much until that time.

00:56 Let’s look at the schedule for routine prenatal care first.

00:59 So generally, I know this can change based on where you happen to be practicing on the planet.

01:06 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.

01:24 That’s the typical schedule.

01:27 And as I mentioned, that’s for normal healthy patients.

01:29 Patients with diabetes or other, you know, twin pregnancies, they’re going to be seen more often.

01:37 So just to provide some landmarks over these visits, the first visit includes a pelvic examination complete.

01:44 Also, you’re going to initiate folic acid supplementation.

01:48 The recommendation is at least 400 micrograms daily.

01:51 Usually, we’re recommending 1 milligram daily, so 1000 micrograms.

01:57 Body weight and blood pressure checks all visits.

02:01 You should be able to auscultate the fetal heart tones with a Doppler ultrasonography at gestational age 10 to 12 weeks.

02:12 Now at 20 weeks that I mentioned that’s when you’re going to start checking fundal height.

02:15 And at 36 weeks you’re going to check the fetal lie.

02:18 Now, that’s not all we do.

02:20 We’ll fill in some laboratory work and some other recommendations along the line.

02:25 But in terms of clinical examinations those are what you’re going to do.

02:28 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.

02:41 Better evaluated in other ways, through checking your blood pressure you’re doing a glucose tolerance test.

02:47 And whereas before it was recommended that all women undergo cervical cancer screening during pregnancy.

02:54 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.

03:04 If they had it done a year ago and it was normal, no need to repeat it.

03:09 What about labs at the initial visit? Doing a CBC and HIV test, a hepatitis B surface antigen test and hepatitis C antibody with reflex testing, a urinalysis, blood type and Rh screen looking for future incompatibility, rubella immune status, a syphilis test, and gonorrhea and chlamydia testing.

03:31 Many women have a question about their diet in pregnancy, what’s safe to eat, what’s unsafe to eat.

03:39 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.

03:47 But saccharine should be avoided during pregnancy.

03:51 Moderate caffeine intake is also probably safe, so one to two cups of coffee per day.

03:57 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.

04:08 Therefore, avoid those things during pregnancy.

04:12 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.

04:24 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.

04:34 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.

04:47 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.

04:56 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.

05:08 And so let’s talk about weight gain goals during pregnancy.

05:12 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 eventually develop hypertension and diabetes.

05:32 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.

05:42 All right.

05:42 How about some other important pieces of advice during pregnancy, these are common questions that patients are going to have.

05:49 Is it safe for me to go on an airplane? It actually is.

05:51 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.

06:00 So that’s something they should understand before committing to particularly a plane flight of four or more hours.

06:09 Patients will ask you, “Can I exercise?” Absolutely, particularly if they’ve been exercising, that’s certainly recommended actually.

06:16 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.

06:25 Things to avoid: hair treatments, hot tubs and saunas during the first trimester in particular.

06:31 Those can potentially do damage to your pregnancy.

06:35 And for pain, which is really common during pregnancy, acetaminophen is the safest over all.

06:41 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.

07:03 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.

07:15 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.

07:28 Also reduces the risk for a post-dates pregnancy, but not every study of routine ultrasonography have actually demonstrated any benefit during pregnancy.

07:36 And again, it’s probably worth mentioning now that pregnancy is not like many other things we’ve talked about, a disease state.

07:41 This is a natural process that’s part of the life cycle.

07:46 That said, in the United States, most women are offered a single ultrasound at 18 to 20 weeks.

07:51 That’s the best time for doing a fetal anatomy survey and it also fits in in screening for aneuploidy.

07:58 Let’s talk about that.

08:00 So standard in the United States now is a screening system that includes both the first and second trimester testing, and it’s mixed.

08:08 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.

08:15 It demonstrates a fair sensitivity and a strong specificity.

08:20 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.

08:41 A chorio villus sampling is another option.

08:45 The rates of -- amniocentesis is a specialized procedure.

08:50 The risk of an abortion with amniocentesis is about 0.5% or so.

09:00 So it’s very rare to have a serious complication, but it is something that needs to be explained to patients before the procedure.

09:07 Another option that has emerged is actually drawing DNA from the maternal circulation and then doing DNA testing on them directly.

09:15 That provides a more accurate means of screening for aneuploidy, but it’s also pretty expensive.

09:23 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.

09:36 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.

09:50 But for other average-risk women they can wait till the second trimester.

09:55 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.

10:09 Repeating urinalysis for bacteria between 11 and 16 weeks of gestation.

10:14 So I would recommend the influenza vaccine to every pregnant women, they are at higher risk for complications of influenza.

10:22 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.

10:43 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.

11:01 So those are some of the guidelines regarding prenatal screening.

11:06 A lot of information in there, a lot of dates to follow.

11:10 But when you do so, you’re really providing the best care for your patients in keeping both mom and baby healthy.

11:16 Thanks.