The Prenatal Journey pt 3

First OB visit interview

• current pregnancy

• OB/GYN Hx

• review of systems

• medical Hx

• nutrition Hx

• Hx of drug use and herbal preparations

• family Hx

• social, experiential and occupaitonal Hx

• Hx of physical abuse

• immunizations?

Preterm

26 weeks to 36 weeks +6

Early term

37 weeks through 38 weeks + 6

Full term

39 weeks through 40 weeks + 6

Late term

41 weeks through 41 weeks + 6

Postterm

42+ weeks

Gravida

number of times the pt has been pregnant, including the current pregnancy

• deliveries (term and preterm)

• spontaneous abortions (miscarriages)

• elective abortions

• medical terminations

Parida

total number of pregnancies >20 weeks

Nulligravida

never been pregnant

Primigravida

pregnant for the first time

Multigravida

pregnant more than once

Nullipara

never completed pregnancy beyond 20 weeks b/c she has never been pregnant OR had a spontaneous/elective abortion

Primipara

delivered one pregnancy at 20+ weeks

Multipara

delivered two or more pregnancies at 20+ weeks of gestation

GTPAL

• gravidity (# of pregnancies)

• term (# of pregnancies carried to term/37+ weeks)

• preterm (# of pregnancies between 20-36 + 6 weeks)

• abortion (# of losses before 20 weeks)

• living (# of living children)

First trimester prenatal visits

• weeks 4-8 - initial visit

• weeks 8-12 - q4 weeks

Second trimester prenatal visits

weeks 13-27 - q4 weeks

Third trimester prenatal visits

• weeks 28-36 - q2 weeks

• weeks 36- birth - every week

Calorie intake?

increase 300 cal/day

Protein intake?

slight increase, 1-2 servings/day

Water/hydration

8-10 (8 oz) glasses per day

Iron intake?

27 mg/day

Folic acid/folate intake?

800 mcg/day minimum

Calcium intake?

1,300 mg/day

Weight gain for BMI <18.5

28-40 lbs

Weight gain for BMI 18.5-24.9

25-25 lbs

Weight gain from BMI 25-29.9

12-25 lbs

Weight gain for BMI >30

11-20 lbs

Health promotion

• continue low-impact, no contact exercise

• rest

• low stress and safe home/work environment

• d/c smoking, alcohol, substance abuse

• avoid overheating

• review OTC meds w/ doctor

Screening

assessing the risk of genetic diseases, NOT diagnostic/definitve

Diagnostic

confirmation of a fetal condition/disorder

First trimester screening tests

• DNA testing

• dating ultrasound

• H&H

• blood type/Rh antibody

• syphillis test (RPR)

• rubella

• hepatitis B screen

• HIV

First trimester diagnostic tests

chronic villus sampling (CVS)

TORCH infections

a group of maternal infection that can harm the embryo/fetus

• Toxoplasmosis

• Rubella

• “Other”

• Cytomegalovirus (CMV)

• Herpes simplex virus type 2 (HSV-2)

Other in TORCH

hepatitis B, syphilis, HIV

Greatest risk of exposure?

during the first 12 weeks of gestation - developmental abnormalities

Second trimester screening tests

• MSQS

• anatomy scan (U/S)

Second trimester diagnostic test

amniocentesis

Third trimester screening tests

• fetal kick counts

• GTT (glucose tolerance test)

• GBS

• H&H

• blood type/Rh antibody

• syphilis test (RPR)

Third trimester advanced fetal assessment

• ultrasound/growth

• NST/BPP

• doppler studies

Free fetal cell DNA maternal serologic testing

NOT ROUTINE SCREENING

• can be done as early as 10 weeks

• cfDNA fragments of both the pregnant pt and fetus circulate in the blood

• trisomy 13, 18, 21

Who undergoes free fetal cell DNA maternal serologic testing?

high-risk patients

• maternal age >35

• Hx of chromosomal abnormalities

• suggestive results from U/S

• positive results from other serum tests

Chronic villus sampling (CVS)

NOT ROUTINE DIAGNOSTIC

• performed in weeks 10-13

• transabdominal or transcervical

• genetic studies

• does not test for NTDs

• VERY INVASIVE! can affect extremity development

Nuchal translucency U/S

ROUTINE SCREENING

• performed at weeks 11-14

• measruement >3mm have an increased risk of trisomy 13, 18, 21

• PAPP-A/BHcg testing increases the accuracy of NT testing

• does NOT test for NTDs

Maternal serum quadruple screening (MSQS)

ROUTINE SCREENING

• looks at maternal hormonal levels (estradiol, inhibin-A, Hcg, AFP)

• risk assessment for trisomy 13/18/21 and NTDs

• high sensitivity/low specificity

• positive AFP test is not diagnostic!

• valid results during 15-22 weeks

• not used in multiple pregnancies

High AFP means?

possible NTDs

Low AFP means?

possible trisomy 18 or 21

Amniocentesis

NOT ROUTINE DIAGNOSTIC

• performed at 15+ weeks

• detects trisomy 13, 18, and/or 21

• hemolytic disease

• VERY INVASIVE - can lead to spontaneous miscarriage

  • vaginal bleeding/leaking of amniotic fluid after procedure

1 hour gestational diabetes screening (OGTT)

ROUTINE SCREENING

• tested around 28 weeks, unless otherwise indicated

• non-fasting test

• 50 gm glucose bolus

• 1 hour BG blood sample

No GDM levels?

<130-140 mg/dL

What levels indicate a failed 1-hour OGTT?

>130-140 mg/dL

3-hour OGTT

NOT ROUTINE DIAGNOSTIC

• performed if failed 1-hour OGTT

• fasting test

• 100 gm bolus

• FBS, 1 hour, 2 hour, 3 hour

What confirms GDM?

two values above the designated thresholds

GBS screening

ROUTINE SCREENING

• performed around 36-37 + 6 weeks

• collect a genital swab for the detection of group B streptococcus (GBS)

Advanced fetal assessment for third trimester

NOT ROUTINE SCREENING

• for high-risk pts

• NST, BPP, Doppler studies

• begin at 32 weeks until delivery (r/t pt history and present condition)

• testing frequency is condition dependent

Reactive non-stress test (NST)

2 or more FHR accelerations of 15 BPM lasting 15 seconds, occur w/n a 20 min time frame

Reactive NST is?

a good sign, indicates fetal well-being

Non-reactive non-stress test (NST)

NOT ROUTINE SCREENING

• doesn’t meet criteria for reactivity

• indicates further testing needed

  • additional time for NST

  • BPP

Non-reactive NST means?

BAD SIGN!

Advanced fetal assessment >= 32 weeks

• biophysical profile (BPP)

• EFM + ultrasound

• scoring system 0-10

• out of 8 is common

• BPP <= 6/10 needs further action

What does a BPP <= 6/10 indicate?

consider delivery based on gestational age, etc.

Doppler studies

• a measure of the velocity of blood flow in the umbilical artery

• decreased, absent, and reverse flow indicates worsening placental insufficiency

Indications for doppler studies?

• potential for progressive utero-placental insufficiency

• intrauterine growth restriction (IUGR)