Maternity Care I By: Brittany Wyger, MD (PGY-III).

Maternity Care IBy: Brittany Wyger, MD (PGY-III)

Routine physical exam including pelvic exam at initial visitDetect reproductive tract abnormalities & screen for STI

Maternal weight at all visitsHeight and weight at first visit to determine BMI

Maternal BP at all visits Identify chronic HTN, preeclampsia or gestational

hypertensionFetal HR auscultation after 10-12 weeks with doppler

Used to confirm viable fetus, HR range = 110-160 Fundal height after 20 weeks

Fundal height in cm should roughly equal gestational age in weeks

Fetal lie by 36 weeksAbdominal palpation with Leopold maneuvers

Physical Exam and Counseling

Leopold Maneuvers

Calorie intakeMost women require an additional 300-400 cal per day

Recommended weight gain for BMISingleton pregnancy

BMI <18.5 (underweight) — weight gain 28 to 40 lbs BMI 18.5 to 24.9 (normal weight) — weight gain 25 to 35 lbs BMI 25.0 to 29.9 (overweight) — weight gain 15 to 25 lbs BMI ≥30.0 (obese) — weight gain 11 to 20 lbs

Twin pregnancy BMI <18.5 (underweight) — no recommendation due to insufficient data BMI 18.5 to 24.9 (normal weight) — weight gain 37 to 54 lbs BMI 25.0 to 29.9 (overweight) — weight gain 31 to 50 lbs BMI ≥30.0 (obese) — weight gain 25 to 42 lbs


Evaluation for edema >1+ pitting edema after 12 hours bed rest or weight

gain of 5 lb in 1 week Occurs in 80% of pregant women and lacks specificity

and sensitivity in diagnosing preeclampsia Urinalysis

To evaluate for asymptomatic bacteriuria and protein Pap smear should be offered

Based on age (>21) and pap history Oral exam

Periodontal disease associated with increased risk of preterm birth

Dietary counseling and folic acid supplementation 0.4mg daily recommended (4 weeks before conception

ideally) to help prevent neural tube defects If previous fetus with NTD or family history, 4mg

recommended daily


Every Prenatal Visit

Physical exam and counseling on prenatal topics pertinent to current gestational age of pregnancy

UrinalysisVital signs, height and weightDoppler for fetal heart tones starting after week

10Fundal height measurement after 20 weeksFetal lie by Leopold maneuvers after 36 weeks

(you can also do transabdominal US to confirm vertex positioning)

Pelvic exam for cervical change and station after 36 weeks

Initial prenatal visitUrine pregnancy test to confirm pregnancyPap smear only if age >21 and not currentGC/Chlamydia genprobe

USPSTF recommendation (2005) If <25 years old Engaging in high risk sexual behaviors (incl those living in high

prevalence areas…aka Louisiana), drug use, multiple partners, no barrier contraception, incarcerated

(if positive treat with Rocephin & Zithromax respectively)

Wet prep only if they complain of discharge (if trich positive treat with Flagyl)

Pelvic examDating based on LMP (Naegle’s rule)

LMP (1st day) + 1 year – 3 months + 7 days LMP- 07/23/2014, EDD- 04/30/2015

Refer immediately for OB ultrasound to confirm gestational age (earlier the US, the more accurate the dates)

Initial prenatal visit

Prescribe prenatal vitamins, can also recommend prenatal/ OB gummy vitamin if patient does not tolerate regular prenatal vitamins

Influenza vaccination (can be given in any trimester)

Genetic screen/ Risk assessment If high risk OB recommend referral to

fetal-maternal medicine, Dr. Rodts-PalenikOrder OB panel labs

OB Panel Labs

CBC, CMPUrinalysis, Urine culture, UPT (treat

asymptomatic bacteriuria in pregnancy)RPR (treat with Penicillin G Benthazine)HIV (antiretroviral therapy)Rubella IgG (if non-immune, vaccinate after

delivery)Hepatitis B surface antigen (treatment is active

and passive immunization of infant after delivery)Antibody screenABO/Rh (if Rh- neg will need rhogam)

OB Labs

Sickle cell screen (if African-American or Caribbean descent)

+/- Cystic Fibrosis screeningCervical cytology (as needed)

HPV co-test<30 years of age- reflex (ASCUS) every 3 years>30 years of age- routine with pap every 5

years

At 16-20 weeksMaternal quad screen (16 weeks)

If abnormal, patient may want further testing (amniocentesis)

Refer for OB ultrasound to assess fetal anatomy (18-20 weeks) and placental location

At 24-28 weeksGestational diabetes screen (O’Sullivan)- 1

hour GTT (50g oral glucose load)If CBS >140, recommend 3 hour GTT, if >190

skip 3hr3 hr GTT 1 hr<180, 2hr <155, 3hr <140

Administer RhoGam if Rh negative patient (28 weeks)

Repeat H&H to evaluate for anemia STI testing if increased risk Refer to OBGYN for BTL if requested by

patient (they must sign consent forms several weeks in advance)

Tdap vaccination (28-32 weeks)

At 35-37 weeksGroup B strep

If positive, treat with intrapartum antibiotic prophylaxis (PCN)

Fax records to L&DGive patient pager number or cell number if

you so chooseCounsel on labor & delivery preparation,

where to go, who to call, signs of labor etc.

At 40-42 weeksInduction of labor not recommened before 40

weeks If you and your patient choose induction, you

must speak with Dr. Madden ahead of time and reserve a room in L&D (they usually need 1-2 days notice)

L&D (318) 769-7030

Clinic visits recommened every 4 weeks from intial visit to 28 weeks gestation

From 28-36 weeks recommend routine prenatal visits every 2 weeks

After 36 weeks recommend routine prenatal visits weekly

These are approximate and will change if patient is high risk OB

Artificial sweetenersSaccharin known to cross placenta and may remain in

fetal tissueCaffeine

Limit to 150-300mg per day, high dose associated with spontaneous abortion and low birth weight

DairyAvoid unpasteurized and soft cheeses (feta, brie,

mexican queso), risk of Toxoplasma and Listeria Deli foods

Avoid deli metas, paté and meat spread, risk of ListeriaEggs

Avoid raw eggs (ceasar salad, eggnog, raw cookie dough), risk of Salmonella

Dietary Guidelines in Pregnancy

Seafood Avoid shark, swordfish, mackerel, tilefish, tuna steaks, raw

fish (sushi), shellfish Limit intake of other fish (incl canned tuna) to 12 oz per week Risk of Listeria, parasites, norovirus, organic pollutants

(polychlorinated biphenyls and dioxins), high mercury levels can cause neurologic abnormalities in mother and fetus

Herbal teas Avoid chamomile, licorice, peppermint, raspberry leaf Associated with uterine contraction, increased uterine blood

flow, spontaneous abortionMeat

Avoid undercooked meat, risk of Listeria and Toxoplasma Excessive consumption of liver products can cause Vit A

toxicityLeftovers

Thoroughly reheat before eating, risk of Listeria

Dietary Guidelines in Pregnancy

Air travel Safe up to 36 weeks, long flights increased risk of DVT Consider the availability of medical resources at destination

Breastfeeding Recommended as best feeding method Contraindicated in HIV, illicit drug use and certain medications

Childbirth education Several childbirth classes are offered, increases maternal

confidence but does not change overall birth outcomesExercise

30 mins moderate exercise most days of the week recommended Avoid activities that put patient at risk for falls or abdominal

traumaFetal movement counts

Not recommended, increases maternal anxietyHair treatments

Avoid during pregnancy, however not explicitly linked to malformation

Counseling Topics

Heavy metalsAvoid because of potential for delayed fetal neurologic

developmentHerbal therapies

Avoid ginko, ephedra & ginseng (known to be harmful to fetus)

Hot tubs/ saunasAvoid in 1st trimester, heat exposure linked to NTD &

miscarriageLabor & delivery

What to do if membranes rupture, where to go, who to call, pain management plan, support system during delivery

Medications & OTCRisk and benefits of medications

RadiationAvoid ionizing radiation (may affect fetal thyroid

development)

Counseling Topics

Workplace issuesProlonged standing, exposure to certain

chemicals or radiation in the workplaceSeat-belt use

Use 3 point seatbelt with shoulder strapSex

May continue during pregnancy, contraindicated in placenta previa

SolventsAvoid exposure particularly in areas without

adequate ventilation, increase risk of miscarriage

Counseling Topics

Substance useAlcohol

Screen pregnant women for alcohol useNo amount of alcohol has been proven safe in

pregnancyFetal alcohol syndrome

TobaccoScreen pregnant for tobacco useOffer smoking cessation counselingIncreased risk of low birth weight

Illicit drugsInform pregnant women of potential adverse

effects on the fetus, detoxification programs, methadone therapy in opiate addiction

Counseling Topics

Accurate dating as early as possible in the pregnancy is essential

UPT usually positive within 1 week of missed mensesNaegele’s rule

LMP (1st day) + 1 year – 3 months + 7 daysEx: April 7, 2014 = LMP

EDD- January 14, 2015Early US can accurately date the pregnancy &

evaluate for multiple gestationAccurate within 4-7 days in 1st trimester, 10-14 days in 2nd

trimester, 21 days in 3rd trimesterUS performed at 18-20 weeks gestation for fetal

anatomic screening

Dating of Pregnancy and US

Risk of developing alloimmunization for an RhD negative woman carrying an RhD positive fetus is approximately 1.5%

Risk reduced to 0.2% with RhoGam administration

RhoGam is Rh(D) immune globulinABO and Rh testing should be performed at

initial visitRh negative women should be given

RhoGam (300mcg) at 28 weeks and again within 72 hours of delivery if infant has RhD-positive blood

Alloimmunization

RhoGam should also be given if risk of fetal-maternal transfusion is increased (CVS, amniocentesis, external cephalic version, abdominal trauma, bleeding in 2nd or 3rd trimester)

Alloimmunization is uncommon before 12 weeks

Threatened early spontaneous abortion RhoGam 50mcg

Alloimmunization

Iron deficiency anemiaAssociated with increased risk of low

birth weight & preterm delivery All pregnant women should be screened at

initial visit and treated with supplemental iron if indicated (in addition to prenatal vitamin)

Pregnant women who do not respond to iron supplementation within 4-6 weeks should be evaluated for other conditions (malabsorption, ongoing blood loss, thalassemia, other chronic diseases)

Anemia

Most organizations recommend that all pregnant women be offered screening

Invasive genetic testing should be offered to women >35 years of age

Aneuploidy screening Nuchal translucency testing + serum testing

(9-11 weeks gestation) and serum testing again (15-19 weeks gestation)

If screening test is positive, offer amniocentesis (>15 weeks gestation) or chorionic villous sampling (11-13 weeks gestation)

Genetic Testing and NTD

Prenatal Screening Tests for Down SyndromeFirst trimester screening

Nuchal translucency, free β-hCG, PAPPA (pregnancy associated plasma protein A), maternal age

Quadruple screening (second trimester)Unconjugated estriol, α-fetoprotein, free β-hCG,

inhibin A, maternal ageIntegrated screening (first and second trimesters)

Nuchal translucency, PAPPA, α-fetoprotein, unconjugated estriol, free β-hCG/total hCG, inhibin A, maternal age

**Most common reason for false positive is incorrect EGA**


Other screening tests offered to those with genetic risks based on family history of the patient and her partner

Examples include:Cystic fibrosisTay-sachsCanavan diseaseSickle cell diseaseThalassemias


Affect 1.5 per 1,000 pregnanciesDetected by testing maternal serum alpha-

fetoprotein levels (elevated MSAFP)Folic acid supplementation recommended

early, ideally prior to conceptionFolic acid 400mcg daily before pregnancy

and continued until 12 weeks gestation decreases the rate of NTD by 75%For those on anti-seizure meds Valproate or

Carbamazepine 4mg folic acid per day recommended

Neural Tube Defects

Measure TSH in women with history of thyroid diease, Type-1 DM, other autoimmune diseases, family history of autoimmune diseases or any symptoms of thyroid disease

Thyroid disease causes increased risk of pregnancy loss, preeclampsia, low birth weight, thyroid storm, prematurity and maternal CHF

Women with hypothyroidism prior to pregnancy will need increased doses of Synthroid Goal TSH <2.5 mIU

Thyroid Testing

Bacterial vaginosis Universal screening not recommended

Rubella Screen for Rubella immunity at first visit, ideally should be before

conception (when vaccination is safe) Non-immune patient’s should be given MMR postpartum, MMR is

contraindicated during pregnancy but can be given during lactation Varicella

Screen through maternal history Maternal varicella can cause congenital varicella syndrome (low

birth weight, limb/ophthalmologic/neurologic abnormalities) and neonatal varicella

Maternal shingles is not a risk (passive maternal immunity) Some evidence to support serologic testing if unknown immunity Non-immune women should receive vaccination postpartum and

avoid exposure during pregnancy Varicella-zoster IG therapy may be given in the event of recent

exposure

Infectious Disease

Asymptomatic bacteriuria >100,000 cfu of a single bacterial species, E.coli – most common Complicates 2-7% of pregnancies Screen at 11-16 weeks If patient has sickle cell trait then screen q trimester Treat to reduce risk of UTI, pyelonephritis and preterm labor Treatment of choice- Cephalexin 250mg po QID x7d (ampicillin

no longer recommended due to high resistance rates) Repeat urine cx after therapy to ensure cure

Influenza Vaccinate for influenza including household contacts Can be given at any time during the pregnancy

Tetanus and Pertussis Vaccinate at 27-36 weeks gestation for best antibody response

and passive immunity to the fetus

Infectious Disease

Group B StreptococcusScreen at 35-37 weeks gestationTreat with intrapartum antibiotic prophylaxis

(PCN, Clindamycin (if PCN allergy and susceptible)), use vancomycin if resistant to Clinda

Treatment indicated also for anyone with GBS bacteriuria at any stage of pregnancy or with unknown GBS status and risk factors including: preterm birth, ROM >18 hours or maternal fever

Women with negative GBS Cx within 5 weeks of delivery do not require Abx even if risk factors develop (delivery <37 weeks, ROM >18 hrs, intrapartum temp>100.4)

Infectious Disease

Chlamydia- screening recommendedTx- Azithromycin, erythromycin, clindamycinCongenital eye infections, pneumonia, preterm

birthGonorrhea- screening based on personal or

geographic riskTx- Cefixime (Suprax), Ceftriaxone (Rocephin)Chorioamnionitis, preterm birth, low birth

weight, congenital eye infectionsHPV Condylomata- screening not indicated

Tx- cryotherapy, trichloroacetic acidVertical transmission, self-limited, usually

minor

Sexually Transmitted Infections

Hep B- screening recommendedTx- active and passive immunization of the infantVertical transmission

HSV- screening not indicated, history should be askedCulture or PCR testing of lesionsTx- Acyclovir or Valacyclovir prophylaxis at 36

weeks for HSV history, suppressive therapy recommended 36 weeksdelivery

Vertical transmission risk, c-section for patient with active lesions at delivery

HIV- screening recommended Tx: Antiretroviral therapyVertical transmission


Syphilis- screening recommendedRPR or VDRLTx: Penicillin G benzathineCongenital syphillis

Trichomonas- screening not indicatedTx- Metronidazole (Flagyl)Preterm birth, PROM, low birth weight


Considered safeAmoxicillinAmpicillinClindamycinErythromycinPenicillinCephalosporins

Typically avoidTetracyclinesNitrofurantoin*Sulfonamides** Mixed evidence of potential birth defects per ACOG

Antibiotics in Pregnancy

Gestational DiabetesComplicates 2-5% of pregnanciesAssociated with hypertensive disorders,

macrosomia, shoulder dystocia and c-section deliveries

ACOG recommends screening early in pregnancy for those at risk (hx of gestational DM, obesity or known glucose intolerance) with HbA1C or fasting glucose

All pregnant women should be screened at 24-28 weeks with a 1 hour GTT (50g glucose load)

Abnormal 1 hour GTT should be followed by a 3 hour GTT (100g glucose load)

Fasting glucose <951 hr GTT 1 hr<140 (if >190 skip the 3hr GTT)3 hr GTT 1 hr<180, 2hr <155, 3hr <140

Complications of Pregnancy

Ectopic PregnancyRisk factors:

Previous ectopic pregnancy In utero DES exposureHistory of STI or infertilityCurrent smoking

Diagnosis: Abdominal pain & vaginal bleeding, approximately 7

weeks after LMP US is diagnostic test of choice (no intrauterine

gestational sac) Transabdominal US: β-hcg >3500 Transvaginal US: β-hcg >1800


Ectopic PregnancyDiagnostic curettage: used when β–hcg

levels falling or levels are elevated and US does not show IUPIf chorionic villi not detected, suspect ectopic

pregnancyDecreasing β-hcg follow hcg titersRising or stable + mass >4cm

laparoscopy/laparotomyRising or stable + mass <4cm Medical

treatment


Ectopic PregnancyTreatment:

Hemodynamically unstable LaparotomyStable patient/ Early diagnosis

Laparoscopic salpingostomy Medical management with Methotrexate

MTX contraindicated: Breastfeeding, immunodeficiency, liver disease, blood dyscrasias, acute pulmonary disease, PUD, renal disease


Hypertension in PregnancyBP measured at each clinic visitCounsel patients on warning signs of

preeclampsiaPts with chronic HTN or preeclampsia in

previous pregnancy should have baseline urine protein

Safe medications inlude: Methyldopa (Aldomet), Nifedipine (Procardia) and Labetalol (Trandate)


Preterm BirthBefore 37 weeks gestation>500,000 preterm births annually in the USProgesterone IM weekly from 16-37 weeks

gestation reduces preterm birth by 35% in women with hx of PROM or spontaneous preterm labor

Very expensive and hard to find at most pharmacies

Cervical cerclage may reduce risk in women with shortened cervical length with previous preterm birth


Posterm PregnancyDecreased risk of perinatal death among

women induced at 41 weeks vs expectant management to 42 weeks gestation

Rate of meconium aspiration was lower with induction but no difference in rate of c-section delivery or operative vaginal delivery

Counsel patients on risks and benefits of both options

Twice weekly NST and weekly AFI testingInduction recommended if AFI <5mL or max

vertical pocket <2cm at term


THANK YOU!

Which one of the following is a standard component of all prenatal visits? (check one)

A: Breast examinationB: Maternal weight measurement C: Assessment of fetal lieD: Pelvic examination

Review Questions

B: Maternal weight measurement

Answer

All pregnant women should be screened for which one of the following sexually transmitted infections? (check one)

A: Hepatitis B virusB: GonorrheaC: Herpes virusD: Trichomonas

Review Questions

A: Hepatitis B virus

Answer

Which one of the following vaccinations are safe to give during pregnancy? (check all that apply)

A: InfluenzaB: Diptheria & TetanusC: MMRD: VaricellaE: BCG

Review Questions

A: InfluenzaB: Diptheria & Tetanus

Answer

When should a healthy pregnant patient be screened for gestational diabetes? (check one)

A: 10-14 weeks gestationB: 16-20 weeks gestationC: 24-28 weeks gestationD: 30-34 weeks gestation

Review Questions

C: 24-28 weeks gestation

Answer

How much folic acid supplemenation is recommended for a patient with a family history of neural tube defects? (check one)

A: 40mcg dailyB: 400mcg dailyC: 4mg dailyD: 40mg daily

Review Questions

C: 4mg daily

Answer

Maternity Care I By: Brittany Wyger, MD (PGY-III).

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Transcript of Maternity Care I By: Brittany Wyger, MD (PGY-III).