PRENATAL CARE

1. PRENATAL CARE Linda A. Goodrum, M.D. Assistant Professor Division of Maternal Fetal Medicine

2. INTRODUCTION Definition: a manner of organizational preventative care in which services and counseling are provided at regular intervals in the hopes of achieving an optimal pregnancy outcome. Preconception care and counseling a major component Unknown exactly what aspects of prenatal care are most beneficial

3. HISTORY Mrs. William Lowell Putnam � began a type of �home health� care service in early 1900�s Dr. Josephine Baker � prenatal care program in New York City Prenatal care initially organized to manage preeclampsia and preterm labor Preconception care has taken longer to develop

4. HISTORY Prenatal care initially performed by public health nurses Observational studies showed improved neonatal outcome Maternity centers evolved later in the century � education and maternal history/physical exam were added components Official guidelines then instituted

5. GENERAL COMPONENTS Risk Assessment: history and physical, fetal well-being, laboratory tests Promotion of healthy lifestyles and counseling on behavior modification Education and preparation Interventional therapies Preconception counseling/contraception

6. GENERAL GUIDELINES What should prenatal care encompass? Who does it benefit? Why is prenatal care important? What is it about prenatal care that is beneficial? What should be standard visit schedule? Should current concepts be revised?

7. BARRIERS TO CARE Shame or fear over pregnancy Distrust of health care system Transportation problems Cultural beliefs Socioeconomic factors Lack of child care Complicated eligibility system and long waits Not aware of importance of prenatal care

8. ADEQUACY OF CARE ACOG standards Kessner index � trimester care began + total number of visits + gestational age at delivery Adequacy of Prenatal Care Utilization Index � subdivided into time of first visit and % of visits completed prior to delivery Only deal with quantity, not quality of care Must consider whether high risk

9. RISK ASSESSMENT Medical History Obstetric History Surgical History Immunizations Medications Initial fetal assessment/ultrasound Contraception Gynecologic History Infectious disease exposure

10. GENETIC HISTORY Previous child with birth defects or genetic disorder Ethnicity Caucasian � cystic fibrosis African American � sickle cell disease Mediterranean � beta thalassemia Hispanic � beta thalassemia French Canadian/Ashkenazi Jews � Tay Sachs

11. GENETIC HISTORY Family History of birth defects, aneuploidy, mental retardation Teratogen exposure � home, work environment Substance abuse Maternal age Risk for pre-existing diabetes ?Paternal age

12. SOCIAL HISTORY Substance abuse Social support Screen for domestic abuse Financial preparedness Exercise and nutritional habits Tobacco use Occupational and home exposures

13. EMOTIONAL ISSUES Depression Grief Marital discord Ambivalence about pregnancy Poor social support Low self-esteem and coping strategies Other issues associated with extremes of age

14. PHYSICAL EXAM Thyroid Lung Cardiovascular Skin Vaginal and Pelvic Breasts Assessment of uterine size Dental hygiene

15. LABORATORY Blood type and Rh factor Antibody screen RPR HIV Hepatitis B Rubella PAP/GC/Chlamydia

16. LABORATORY Urinalysis or urine culture Urine drug screen Triple marker screening One hour glucola CBC ?TSH, Hepatitis C

17. FREQUENCY OF VISITS Based on ACOG standards Initial visit first trimester Visit every 4 weeks until 28 weeks� Visit every 2 weeks from 28-36 weeks� Weekly visits at term until delivery Postdates: twice weekly fetal testing Applies primarily to �low risk� women

18. COMPONENTS OF VISITS Blood pressure check ?Pulse Urine dip for glucose and protein Maternal weight Fetal heart tones Assessment of fundal height

19. PHYSICAL FINDINGS Chadwick�s sign Nausea � �morning sickness� Breast fullness and tenderness Striae gravidarum Fatigue Increased vaginal discharge

20. PHYSICAL FINDINGS Melasma Spider angioma/palmar erythema Hemorrhoids Pigmentation of linea alba Nasal congestion Placental/mammary souffle Diastasis recti

21. IMMUNIZATIONS Tetanus Travel Hepatitis/heptavax Influenza Pneumococcal MMR Varivax

22. DETERMINATION OF EGA Date of Last Menstrual Period Early Ultrasound Naegele�s Rule Pelvic Examination

23. TRIPLE SCREEN Measurement of three analytes in maternal serum Beta HCG MSAFP Unconjugated Estriol Weight, race, diabetic status, age, obstetric history, presence of multiple gestation affect results Gives risk for infant with Trisomy 21 or Neural Tube Defect

24. TRIPLE SCREEN Obtain between 15-21 weeks� Abnormal results: ultrasound for anatomy and dating, amniocentesis, fetal blood sample, genetic counseling, repeat test Analyte profile for trisomy 21 Analyte profile for neural tube defect

25. DIABETES SCREENING Usually performed at 28 weeks, but can be done earlier Decision can be based on risk factors or can utilize universal screening 50 gram load Elevated: > 140 mg/dl Proceed with 3 hour GTT Identifies those with gestational diabetes

26. RHOGAM Immunization that contains anti-D antibodies Given to Rh negative women at 28 weeks� Prevents Rh isoimmunization in fetus Administer at time of miscarriage, termination, amniocentesis, delivery, trauma, episodes of vaginal bleeding 350 micrograms = 30 ml�s whole blood FMH

27. COMMON QUESTIONS Medication use during pregnancy and breastfeeding Work Traveling Prenatal classes Herb use during pregnancy Exercise

28. NUTRITION Adequate weight gain Folic acid Total iron requirements: 1 gram Assess for nutritional risk factors Need additional 300kcal/day Special diets Pica

29. IMPROVING PRENATAL UTILIZATION Community outreach and education Cultural sensitivity Improvements in access to care and waiting times Recognition of socioeconomic barriers to care Encourage preconception counseling and easy availability to contraception