PRENATAL CARE MISCELLANEOUS


General Screening at intake:

  • Type & Rh--Recommendations per USPSTF & AAFP 2005:
  • Should check Rh(D) type at first prenatal visit
  • If Rh-negative:
  • Check for anti-Rh antibodies (indicating sensitization; Often done anyway at first prenatal visit)
  • At 24-28wks (unless biologic father is known to be Rh-negative):
  • Give Rh(D) immunoglobulin (RhOGAM, 300ug) 
  • If unsensitized, check for antibodies
  • When baby is delivered, check baby's blood type and if Rh(D)-positive or weakly R(-positive, e.g.D-mu-positive), give RhOGAM again < 72h after delivery)
  • If pt has amniocentesis or induced or spontaneous abortion (unless biologic father is known to be Rh-negative):
  • If > 13wks gestation, give full-doseRhOGAM (300ug)
  • If 0-12wks, give "mini-dose" (50ug)
  •  

  • Rubella serology
  • HCT
  • Cervical assays for gonorrhea and chlamydia
  • Wet mount for Vaginitides--BV & Trichomoniasis are commonly tx'd if present though evidence of benefit is unclear--See link for info; USPSTF recommends against testing in women at low risk for preterm birth and makes no recommendation for or against this testing for those at high risk as of 2008; AAFP recommends against screening average-risk women.
  • Pap
  • RPR to screen for syphilis
  • HIV Ab testing
  • Hepatitis B surface antigen
  • Urinalysis and urine culture to screen for asymptomatic bacteriuria (at 12-16wks or 1st prenatal visit per AAFP 2006)
  • Hb electrophoresis if indicated
  • PPD if indicated
  • UDA if indicated
  • Other routine prenatal care issues

    1. Toxoplasmosis issues (See also "Toxoplasmosis in Pregnancy")
      1. At initial visit, ask IF PATIENT HAS CATS which can transmit the disease
      2. In some countries, serologic testing for toxoplasmosis is done routinely, with follow-up testing during pregnancy if pt is seronegative.
    2. High caffeine intake may be associated with reduced fetal growth, some recommend limiting to < 200mg/d (one 12oz cup of drip coffee)
    3. Down Syndrome Screening--See under "Screening for Congenital Abnormalities"
    4. Screen for Group B Streptococcus at 36-37 wks
    5. Influenza vaccine of women who will be in 2nd or 3rd trimester during influenza season
    6. Tay-Sachs screening for pts with Ashkenazi Jewish ancestry
    7. Screening for thyroid disorders
      1. Overt maternal hypothyroidism, if not adequately replaced is associated with intellectual impairment in the infant
      2. Subclinical Hypothyroidism in pregnancy
        1. In a prospective study in 404 women with subclinical hypothyroidism discovered on routine testing at their initial prenatal visit at < 20wks, compared to women with normal thyroid hormone levels, had sig. increased risk fir abruptio placentae (RR 3.0), delivery at < 35wks (RR 1.8), and respiratory distress of the newborn during the neonatal period (RR 2), even after adjustment for maternal age (Obs. Gyn. 105:239, 2005--JW)
      3. Treatment of euthyroid pregnant women with positive thyroid peroxidase antibodies
        1. In a study in which 115 pregnant women who screened positive for thyroid peroxidase antibodies but with normal TSH and free T4 levels who were randomized to levothyroxine treatment (calculated by body weight; mean dose about 50 mcg/d) vs. placebo, the treated women had sig. lower incidence of spontaneous abortion (4% vs. 14%) and preterm birth (7% vs. 22%).  Note that the study was conducted in Italy where iodinization of salt is not compulsory (J. Clin. Endocrin. 91:2587, 2006--AFP)
    8. Cystic Fibrosis screening
      1. Current DNA screening can detect up to 90% of heterozygotes
      2. Only worth considering if parents might choose abortion if baby has CF
      3. Recommended for all pregnant women by NIH (NIH Consens Statement Online 1997 April 14-16, 15(4): in press.)
      4. If mom screens positive, test dad; if both screen positive, consider testing fetus through amniocentesis or chorionic villus sampling
    9. Folic acid supplementation for prevention of neural tube defects:
      1. For average-risk women, folic acid 0.4mg QD starting at least 1mo prior to pregnancy and 0.6mcg during pregnancy
      2. For women with previous offspring with neural tube defects, or women on anticonvulsants, should take 4mg (not 0.4) QD from 1mo before to 3mos after conception
    10. Vitamin C for prevention of premature PROM
      1. No randomized trials as of 2003 but poor dietary intake of vit. C ass'd with increased risk of preterm PROM in one study--See section on PROM for details
    11. Perineal massage in 3rd trimester to prevent perineal laceration with vaginal delivery
      1. 1527 women (493 w/prev. vag. birth, 1034 w/o prev. vag. birth) randomized to perineal massage 10min/d* from 34th or 35th wk until delivery vs. no advice re: perineal massage. Likelihood of delivering vaginally w/intact perineum (nothing more than nonsutured 1st-degree lacs) in essential nullips was 24% in massage group and 15% in usual-care group (sig.; Most of the difference appeared to come for a decreased risk of sutured first-degree tears and episiotomies in the massage groups) and in multipls was 35% vs. 32% (nonsig.). There were no sig. differences in massage groups in incidence of episiotomy, 3rd-degree lacs, or 4th-degree lacs in nullips or multipls.(Am. J. Obs. Gyn 180:593, 1999)
        1. *--"Introducing 1 or 2 fingers 3 to 4 cm deep into the vagina and applying and maintaining pressure, first downward for 2 minutes and then for 2 minutes to each side of the vaginal entrance. Women were given a bottle of sweet almond oil (Rougier Inc, Montreal, Quebec, Canada) to use for lubrication."
      2. 861 nulliparous women randomized (single-blind) to perineal massage vs. no massage. Rates of 2nd or 3rd-degree perineal tears or episiotomies at delivery were 69% in the massage vs. 75% in the non-massage group (p = 0.07) which became significant after "adjustment for mother's age and infant's birthweight." Benefit appeared to be greater in mothers > 30yo. (Br. J. Obs. Gyn 104:787, 1997--abst)
      3. J. Nurse-Midwifery 32:181, 1987--nonrandomized.
      4. J. Nurse-Midwifery 31:128, 1986--140 or the 160 pts randomized were eventually excluded from the analysis
    12. TdaP Vaccination after birth prior to hospital discharge if not previously vaccinated with TdaP and no Td in last 2y.
    13. Dietary recommendations in pregnancy
      1. Caloric intake needs increase by  mean 340 kCal/d in 2nd trimester and 452kCal/d in 3rd trimester
      2. Protein-71g/d
      3. Iron-30mg/d elemental (150mg FeSO4, 300mg Fe gluconate, or 100mg Fe fumarate)
      4. Avoid fish high in methylmercury (shark, swordfish, king mackerel, tilefish, tuna except for canned "chunk light" tuna) in women who might become pregnant (FDA 2001)
      5. Avoid raw fish and shelfish due to risk of hepatitis A and Vibrio
      6. Avoid undercooked meat, poultry, or eggs, particularly prepared meats like hot dogs
      7. Docosahexaenoic acid C22:6n-3 (DHA)
        1. Critical for fetal brain development
        2. However, it is unclear as of 2012 to what degree dietary intake and use of supplements has on fetal development
        3. Best sources are fatty fish (salmon, trout, herring, mackerel, anchovy)
      8. Calcium-1g/d (1.3g for teenagers)

    Gestational age estimation

  • Never use a 3rd trimester u/s to change an EDC unless
  • No 1st or 2nd TM u/s and
  • >3wks diff btwn EDC from 3rd TM u/s and LMP
  • Information for new mothers (from AFP 10/95):

    1. AAFP pamphlets on breastfeeding
    2. Dana N, Price A. Successful Breastfeeding: a Practical Guide for Nursing Mothers. NY: Meadowbrook Press, 1989
    3. Dunnewold A, Sanford DG. Postpartum Survival Guide. Oakland: New Harbinger Publications, 1994
    4. Eisenberg A., Murkoff HE, Hathaway SE. What to Expect the First Year. NY: Workman, 1989
    5. Kleiman KR, Raskin VD. This Isn't What I Expected: Recognizing and Recovering from Depression and Anxiety After Childbirth. NY: Bantam, 1994.
    6. Placksin S. Mothering the New Mother: Your Postpartum Resource Companion. NY: Newmarket Press, 1994

    Also organizations:

    1. Postpartum Support International, 927 Kellogg Ave. Santa Barbara, CA 93111, (805) 967-7636
    2. National Association of Mothers' Centers 336 Fulton Ave, Hempstead, NY 11550 (800) 645-3828