Normal pregnancy and prenatal care

Presumptive signs of pregnancy

Amenorrhea

Tender breasts

Morning sickness d/t hormone surge

Probable signs of pregnancy

Piskacek sign, Hegar sign, Goodell sign, Chadwick sign

Braxton hicks contraction, positive serum or urine pregnancy test -- some meds cause false positives

Piskacek sign

Uterine bulge

Hegar sign

Softening of uterus

Chadwick sign

Blueish cervix, vagina, and labia

Braxton hicks contractions

False labor contractions or practice contractions that usually do not cause cervical changes

Positive signs of pregnancy

Definitively confirm pregnancy --> FHT auscultation, visualization of fetus, positive fetal movement

EDD/EDC

By LMP using Neagele's Tool ONLY if someone has a regular cycle!

By US -- most reliable at 8 weeks gestation

LMP by Neagele's tool

First day of last period, subtract three months, add 7 days

First trimester of pregnancy

First day of LMP through the end of week 13

Second trimester of pregnancy

Week 14 through the end of week 27

Third trimester of pregnancy

Week 28 through the end of week 40+

First prenatal appointment

1-1.5h

Head-to-toe, med/surg hx, gynecological/reproductive hx, lifestyle, genetic testing, confirmation of pregnancy

Head-to-toe at first prenatal appointment

Pap smear if needed

STI screening for chlamydia and gonorrhea

Prenatal labs -- syphilis, T&S, CBC w/ PLT (look at H&H), titers --> rubella, HBV & HCV, HIV, no GBS (too early)

Med/surg hx

Illness and immunizations -- want pregnant women to have up-to-date flu, Tdap, and COVID

Surgeries, detailed hx

Gynecological/reproductive hx

Pap smears -- any abnormal?, increased grade cells w/ hx of HPV

Cervical surgeries --> may cause incompetent cervix, increased number of cervical surgeries increases risk of cervix not staying closed = high-risk pregnancy

IC/partners

Onset of menses/flow/# of days, are they regular

G's & P's (GTPAL)

Type of births and year (past C -- is pt TOLAC or repeat C, incision type; pregnancies closer together increases risk of preterm labor)

LMP: use of pregnancy wheel and/or Naegele's rule

Lifestyle

Ask about SSRIs -- is med safe for pregnancy or does pt need to transition?

Smoking, drinking, illicit drug use?

Exercise -- whatever they did before pregnancy is safe (i.e., if pt is normally sedentary, should not abruptly increase exercise), do they live in a safe neighborhood?

Job -- can they take a break or sit down

Household roles -- Breadwinner? Can they take time off (return to work earlier than 6 wks increases PPD risk and can interfered with breastfeeding)

Screen for IPV and perinatal mental health d/o

Genetic testing — carrier testing for certain populations (CF, Tay-Sachs)

Confirmation of pregnancy by vaginal ultrasound

Vaginal ultrasound

Performed at 8-10 weeks gestation to confirm pregnancy, transvaginal required at this gestational age because uteri's is still in the pelvis, not the abdomen

Prenatal visit schedule

8-10 weeks

12 weeks

18-20 weeks

24 weeks

28 weeks

36-38 weeks

8-10 week prenatal visit

New OB intake — collect hx info

US for dates

Meet w/ provider

12 week prenatal visit

Chromosomal testing done if it is being performed for this pregnancy

If no chromosomal testing —> normal 15 min appointment

18-20 week prenatal visit

Full anatomy scan performed — in-depth look at fetus, examine brain & heart

Can find out sex

24 week prenatal visit

One-hour glucose tolerance test to check for GDM

28 week prenatal visit

Rho GAM given to all Rh negative pregnant people

36-38 week prenatal visit

GBS testing via vaginal rectal swab

Review labor instructions and discuss delivery

Duration of most prenatal appointments

Most appointments will be normal 15 min appointments

Frequency of prenatal visits

For a low-risk pregnancy, prenatal visits q4 weeks until 32 weeks or 8 months of gestation

After 32 weeks/8 months gestation, prenatal visits are every 2 weeks

Starting at 36 weeks, visits will be weekly until birth

If there are additional risk factors that increase risk of pregnancy complications...

Patient will have extra prenatal visits w/ a specialized doctor

First trimester genetic screening

Between 10-13 weeks: blood test for auto-recessive d/o — modified sequential screening, CF carrier screening, Tay Sachs dz

US — nuchal translucency screening

Nuchal translucency (NT) screening

US done between 11 and 14 weeks gestation to look at amount of fluid in the fetal neck (nuchal fold)

Normal NT

3.5 mm

Increase in NT

Increase in fluid could indicate increased risk of cardiac anomalies, trisomy (18 & 21), Turner's syndrome, or viral infection

Second trimester genetic screening

Between 15-22 weeks: Maternal Assays — Quad blood test for trisomy 21 (Downs) & AFP, US — anatomy scan (18-22 weeks)

Diagnostic testing

Chronic villus sample — done at 10-12 weeks, take piece from placenta, increases risk of miscarriage

Amniocentesis — 15-18 weeks, but can be done between 11-14 weeks, remove amniotic fluid sample for microscopic examination, increases risk of miscarriage

Important considerations with genetic testing

There is an increased risk of false positive results if pregnancy is dated incorrectly because testing is based on gestational age

What does TORCH stand for?

T — toxoplasmosis

O — other infections

R — rubella

C — cytomegalovirus (CMV)

H — herpes simplex virus (HSV)/HIV

TORCH infections in pregnancy

Infection transmitted from a pregnant person to their fetus during pregnancy or at the time of birth

Significant cause of fetal and neonatal mortality and childhood morbidity

The earlier the infection is during pregnancy the worse the outcomes (fetal loss)

Cause of toxoplasmosis

Toxoplasma gondii (parasite)

Transmission of toxoplasmosis

Undercooked meat, contaminated water, cat feces

S/Sx of toxoplasmosis in infants

Seizures, chorioretinitis, hydrocephalus

Other infections for the O in TORCH

Syphilis, varicella-zoster, parvovirus B19

Cause of syphilis

Treponema pallidum (bacterium)

S/sx of syphilis in infants

Rash, osteochondritis, hepatosplenomegaly

Transmission of varicella-zoster

Chickenpox during pregnancy

Fetal risks w/ varicella-zoster

Congenital varicella syndrome

Transmission of parvovirus B19

Respiratory droplets

Fetal risks w/ parvovirus B19

Hydrops fetalis (high risk of fetal mortality), fetal anemia

Cause of rubella

Rubella virus

Transmission of rubella

Respiratory droplets

S/Sx of rubella in infants

Cataracts, congenital heart dz, hearing loss, "blueberry muffin" rash

Cause of cytomegalovirus

CMV (herpesvirus family)

Transmission of CMV

Body fluids (urine, saliva, blood, etc.)

S/Sx of CMV in infants

Hearing loss, IUGR, developmental delay, microcephaly, jaundice, "blueberry muffin" rash, thrombocytopenia

Cause of HSV

HSV-1 and HSV-2

Transmission of HSV

Direct contact (often during delivery)

S/Sx of HSV in infants

Skin lesions, encephalitis, disseminated infection, CNS dz, multi-organ involvement

Prevention and management of TORCH infections

Prenatal screening and diagnosis at first prenatal visit

Prophylactic measures — vaccination for rubella

Appropriate tx during pregnancy to reduce fetal transmission (e.g., abx)

Monitoring and intervention postnatally

TORCH screenings on admission for labor

Another syphilis draw on admission for labor

Drawing CMV on admit for labor because rates have been increasing

What is assessed at every prenatal visit

Weight

BP — 120/80 or less is normal

Urine dip

FHT (110-160)

Edema

Positive FM (fetal movement/quickening) after 15 wks

Fundal height

Urine dip

Checking for ketones early on, look for protein at > 20 weeks

Note w/ edema

Some edema is normal in pregnancy, excess edema could indicate preeclampsia

Timeline for counting fetal movement

Count beginning at 28 wks gestation (or 26 wks for high-risk) until birth

Interpretation of # of fetal movements

There should be 10 movements in 1 hr without trying to elicit a response (e.g., drinking something cold, eating something sweet, etc.)

If < 10 movements, patient should call provider & come in for triage (will be put on continuous EFM)

Significance of fundal height

Helps ensure fetus is growing on track

Changes in fundal height w/ gestational increases

12-14 weeks - right above pubic bone

16 weeks - between pubic bone & umbilicus

20-22 weeks - @ umbilicus

24 week - 1-2 finger breadths above umbilicus

40 weeks - 3-4 finger breadths below the umbilicus

Timeline for fetal non-stress test (NST)

Performed in pregnancies 28 weeks gestation or greater

NST

Measures HR of fetus in response to its own movement, involves monitoring the fetus's HR for 20-30 minutes

Acceleration definition for < 32 weeks gestation

10 beats above the baseline for at least 10 seconds

Acceleration definition for > 32 weeks gestation

15 beats bone the baseline for at least 15 seconds

Reactive strip for NST

Normal baseline

2 accelerations

Note w/ NST results

Want good variability

Indications for NST

Post dates

Decreased fetal movement

HTN of any kind

DM/GDM

Multiple gestation

Comorbidities (e.g., lupus)

If baby has a non-reactive NST...

Do something to wake the baby up —> acoustic stimulator (immune > 3x); if still nothing —> BPP

Acronym for aspects of a biophysical profile (BPP)

BATMaN

BATMaN for BPP

B - breathing movement of fetus

A - amniotic fluid volume (AFI)

T - tone of fetus

M - movement of fetus

A - and

N - NST, performed at 28 weeks gestation or greater, additional surveillance if there is a question about the health of the fetus

Considerations w/ BPP

Done via US

Only a snapshot of given moment, may change

Interpretation of BPP results

8-10 is normal, 6 is borderline & may require further testing, 4 is abnormal & may require pregnancy monitoring or labor induction

Alcohol in pregnancy

AVOID alcoholic beverages

Caffeine source and what to do in pregnancy

Found in beverages and some foods

200 mg per day; equal to a 12 oz cup of coffee

Fish w/ high mercury content source and what to do

AKA fish that eat other fish -- large fish (swordfish, shark, albacore tuna, mackerel, etc.)

Avoid fish listed above -- instead, choose low-fat fish, small, white, flaky fish, and shellfish

Guidelines for eating fish during pregnancy

Safe & recommended to eat fish through your pregnancy to maximize Omega-3 fatty acids, mono-unsaturated fats, and protein

Can have 1-2 servings per week of fish & seafoods that are low in mercury

Fish that are safe to eat during pregnancy

Most freshwater fishes are safe to eat

Canned light tuna can be ingested safely

Salmon is a very healthy fish rich in omega-3 fatty acids and can be consumed at least once a week

Fish to avoid during pregnancy

Large, oily fish (fish that eat other fish) because they have higher mercury content in their flesh -- swordfish, mahi mahi, tuna steaks, mackerel, tilefish, sardines, albacore tuna

Unpasteurized foods source and what to do during pregnancy

Cheeses (camembert, brie, moldy or raw cheeses), raw milk, and some juices

Avoid - risk of Listeria, E. coli, Salmonella, Hep A

Raw or undercooked eggs source and what to do during pregnancy

Caesar salad dressing, raw batter or cookie dough, some sauces or creams

Avoid - risk of Salmonella

General diet & nutrition considerations for pregnancy

Think about cultural considerations when modifying pt's diet

Calorie intake ranges in reference to activity levels (more active = more cals needed)

Increase 300 kcal a day based on pre-pregnancy diet

Protein that is safe and well-prepared

Half of body weight in water daily (about 2-3L or 64-96 oz per day)

Why is hydration so important during pregnancy?

Critical to prevent dehydration because dehydration can cause uterine irritability and increase the risk of preterm labor

Purpose of prenatal vitamins & supplements

Cover nutritional gaps

Prenatal vitamins

Contain recommended daily allowance of Folic acid (400 mcg), B vitamins, and iron -- decrease risk of certain birth defects (e.g., neural tube defects like spina bifida)

Prenatal supplements

DHA supplements have been associated with improved neurological development, should be taken in conjunction w/ a prenatal vitamin

Pregnant woman should take at least 1200 mg of calcium per day (2-3 servings)

Ferrous sulfate if needed, take w/ vitamin C to help w/ absorption

If a pregnant individual takes ferrous sulfate...

They are at an increased risk of constipation, talk about bowel regimen

Considerations w/ prenatal vitamins & supplements

Makes patients nauseous -- teach them to take w/ crackers and at bedtime

FDA pharmaceutical pregnancy categories

A, B, C, D, X

Category A medications

Adequate and well-controlled human studies demonstrate no risk

Examples of category A medications

PNV/multivitamin

Category B medications

Animal studies demonstrate no risk, but no human studies have been performed OR animal studies demonstrate a risk, but human studies have demonstrated no risk

Examples of category B medications

Amoxicillin, acetaminophen

Category C medications

Animal studies demonstrate a risk, but no human studies have been performed. Potential benefits may outweigh the risks.

Examples of category C medications

ASA (aspirin), SSRIs

Category D medications

Human studies demonstrate a risk. Potential benefits may outweigh the risks.