Prenatal Care (Clinical)

10/8/24, 13:03 Prenatal Care (Clinical) - Lecturio
Prenatal Care (Clinical)

Prenatal care is a systematic and periodic assessment of pregnant women during
gestation to assure the best health outcome for the mother and her fetus. Prenatal care
prevents and identifies maternal and fetal problems that adversely affect the
pregnancy outcome. Prenatal visits involve scheduled screening tests such as prenatal
ultrasounds or blood glucose tests and measurements of fetal/maternal health metrics.
These visits are also opportunities to educate pregnant women about pregnancy,
labor, delivery, and parenting while providing psychological support to patients and
their families.
Last updated: March 4, 2024
CONTENTS
Initial Prenatal Visit

Subsequent Prenatal Visits
Prenatal Screening for Genetic Abnormalities
Routine Counseling
References
Initial Prenatal Visit

Practice guidelines may vary depending on location. The information provided
here is based on US, WHO, and UK guidelines.
Objectives[1,4,15]
The initial prenatal visit is often the most important. Objectives of this visit include:
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Pregnancy confirmation
Establishing the gestational age and estimated due date (EDD)
A comprehensive medical history and physical exam
Routine laboratory assessments
Counseling[1,4]
Expected course of the pregnancy
Worrisome signs and symptoms to report to the health care team
Safety during pregnancy
Determine the pregnancy risk and establish the follow-up schedule (based on
risk):
Low-risk pregnancy:
Every 4 weeks until 28 weeks' gestational age (wGA)
Every 2 weeks from 28 to 36 wGA
Weekly from 36 wGA to delivery
High-risk pregnancy:
Highly individualized
Visit frequency varies according to disease and response to treatment.
History and exam

Important areas to cover (and why they are important) include:
Obstetric history:[1,4]
Gravidity and parity

Mode of deliveries:
E.g., vaginal or cesarean delivery (CD)
Type of uterine incision during any CD:[13]
Incisions involving the uterine fundus, such as classical and T-incisions,
carry an unacceptably high risk of rupture during labor. Repeat CD
prior to the onset of labor is recommended.
Low transverse uterine incision → may be candidate for a trial of labor
after cesarean (TOLAC)
Individuals with > 2 uterine incisions should have a repeat CD.
Gestational age at prior deliveries:
E.g., full-term or preterm delivery
History of a prior preterm delivery ↑ risk for preterm delivery in this
pregnancy
Prior pregnancy, delivery, and/or postpartum complications:
May ↑ risk for complications in this pregnancy, which may be mitigated with
additional treatments
History of preeclampsia with severe features:
Treat with low-dose aspirin (e.g., 75‒81 mg once daily).[1,2]
Ensure adequate calcium intake; supplement with 1.5‒2 g of oral
calcium daily.[2]
History of gestational diabetes mellitus (GDM): Screen for glucose
intolerance in the 1st trimester and again around 28 wGA.[9]
History of cervical insufficiency/2nd-trimester loss due to painless
cervical dilation: Refer patient to Maternal and Fetal Medicine (MFM) for
consideration of cervical cerclage.[1]
History of spontaneous preterm delivery:[12]
Serial vaginal sonographic assessments of cervical length (every 1‒4
weeks) from 16‒24 weeks
Consider cerclage for cervical lengths < 25 mm.
Consider progesterone supplementation (either vaginal or IM).
History of uterine rupture: Repeat cesarean delivery should be used.[13]
Gynecologic history:[1,4]
Age at menarche
Typical menstrual cycles → to help assess accuracy of pregnancy dating using the
last menstrual period (LMP)
History of genital herpes → patients with genital HSV should:
Receive antiviral prophylaxis with acyclovir starting around 36 wGA
Be evaluated specifically for any signs of active lesions (including on the
cervix) at the onset of labor
Active lesions at the time of labor are a relative contraindication to vaginal
delivery.
Previous gynecologic operations, especially:
Procedures to remove uterine fibroids → women with prior full-thickness
incisions in the uterine fundus should not labor due to ↑ risk of
uterine rupture
Loop electrical excision procedure for abnormal cervical cytology
May ↑ risk of a cervical insufficiency/preterm delivery
Scar tissue may prevent normal cervical dilation and ↑ risk for CD
Past medical and surgical history:[1,4,15]

With the medical history, the physician needs to determine whether the patient has
any conditions that alter the course or risks of pregnancy, and make sure any
conditions that may be altered by pregnancy are appropriately managed. Common
examples of important conditions are:
Diabetes mellitus: requires close management during pregnancy to maintain
normal glucose levels and prevent fetal complications
Hypothyroidism: Levothyroxine dosing often needs to be adjusted during
pregnancy.
Hypertension: ↑ risk for pregnancy complications, especially poor fetal growth and
superimposed preeclampsia
Cardiopulmonary disease: may have ↑ risk with Valsalva during delivery
Thrombophilia (e.g., idiopathic thrombocytopenic purpura): may prevent the safe
insertion of an epidural catheter during labor
Autoimmune disease (e.g., systemic lupus erythematosus):
Pregnancy may cause flares.
Verify safety of medications.
Non-gynecologic surgeries:
For example, if the patient presents with abdominal pain in the
right lower quadrant but has a history of an appendectomy, this rules out
appendicitis.
Family history:[1,4,5]
Family history is important to guide screening for potential inherited conditions in
the fetus.
Inherited diseases (e.g., thalassemia, cystic fibrosis (CF), sickle cell anemia)
Congenital malformations (e.g., cardiac diseases)
Social history:[1,4]
Substance use disorder (may have adverse effects on fetal development):

Smoking
Alcohol use
Drug use disorder
Presence or absence of support system
Screening for domestic violence
Medication and allergies:[1,4]

Medications should be reviewed for:
Safety in pregnancy and lactation
Dosing adjustments
Physical exam:[1,3,4,18]
A complete physical exam should be performed. Special attention should be paid

to:
Vital signs
Height, weight, and BMI
Pelvic exam:
Assess adequacy of the bony pelvis (is there enough space for the fetus to
pass through during delivery?)
Are there any anatomic abnormalities of the vagina, cervix, or perineum that
may affect labor and/or delivery (e.g., presence of a vaginal septum)?
Heart and lung exam
Depression and anxiety screening
Pregnancy confirmation[11]
Pregnancy can be confirmed with:
A urine hCG test
Assessment of the fetal heart rate (FHR) (either by ultrasound if early in the
pregnancy or by handheld doppler)
Pregnancy dating[11]
An EDD should be established at every initial prenatal visit. The 2 primary methods
to do this are:
Estimation using the LMP:

The date that falls exactly 40 weeks after the LMP
Calculated by adding 280 days to the LMP
Calculator (https://www.mdcalc.com/calc/423/pregnancy-due-dates-
calculator)
Ultrasonographic measurements:
Measure the crown-rump length (CRL) and look up the associated date in a
table (though most ultrasound machines will show this along with the
measurement).
After 14 wga, ultrasound (US) dating should be done using a formula
(included in ultrasound software) that uses:
Biparietal diameter (BPD)
Head circumference (HC)
Abdominal circumference (AC)
Femur length (FL)
US dating is most accurate in the 1st trimester before genetic variation and
the effects of intrauterine environment begin to have greater effects on fetal
growth.
Note: Pregnancies that result from assisted reproductive technologies (ART; e.g.,
in vitro fertilization) should be dated based on the type of ART.
Establishing the final EDD:

References have been established to determine whether an EDD calculated by
LMP matches an EDD based on US measurements.
To determine the final EDD:
Use the EDD from the LMP if that EDD is consistent with the EDD obtained
from the ultrasound.
If the EDD from the LMP does not match the EDD obtained from the
ultrasound, use the ultrasound measurement.
Once an EDD has been established, it does not change during the pregnancy.
Note: In the United States, pregnancies are considered suboptimally dated if they
do not have an ultrasound prior to 22 wGA that confirms (or revises) the EDD.
Table: Determining whether a pregnancy should be dated by ultrasound (rather

than LMP)[11]
Gestational age Use US EDD if the discrepancy Method of US

range between US and LMP is measurement
≤ 8 6/7 weeks > 5 days CRL
9 0/7 to 13 6/7 > 7 days

weeks
14 0/7 to 15 6/7 > 7 days BPD, HC, AC, FL

weeks
16 0/7 to 21 6/7 > 10 days

weeks
22 0/7 to 27 6/7 > 14 days

weeks
≥ 28 0/7 weeks > 21 days
AC: abdominal circumference; BPD: biparietal diameter; CRL: crown-rump length; EDD:
estimated due date; FL: femur length; HC: head circumference; LMP: last menstrual
period; US: ultrasound
Ultrasound image of a 12-week fetus:

The broken yellow line is the crown-rump length measurement.
Image (https://openi.nlm.nih.gov/detailedresult?img=PMC3287283_CDI2012-
962923.002&query=crown%20rump%20length&it=xg&lic=by&req=4&npos=4): “Ultrasound image of a 12-week
fetus” by Child Health, Royal Aberdeen Children's Hospital, University of Aberdeen, Foresterhill, Aberdeen AB25
2ZG, UK. License: CC BY 3.0 (https://creativecommons.org/licenses/by/3.0/)
Imaging[2,4,11]
Ultrasonography is the imaging modality of choice and the most accurate tool to
estimate gestational age early in pregnancy (used in conjunction with the LMP). All
pregnant women should have an ultrasound at (or ordered at) the initial visit in
order to confirm:
Pregnancy and fetal viability
Fetus location (intrauterine pregnancy)
Most accurate due date
Number of fetuses and chorionicity in multiple gestations (e.g., twins)
Findings of abnormal uterine and adnexal masses
Laboratory[1,4]
There are a number of routine laboratory tests that should be ordered at the initial
prenatal visit. These include:
CBC
Check for current anemia and thrombocytopenia.
Obtain baseline hemoglobin and platelet counts (to compare future values
to, since anemia and thrombocytopenia are common in pregnancy).
Iron deficiency anemia is the most common.
If present, treat with iron supplementation and retest in 3‒4 weeks[1]
Blood typing and antibody screening
Identify ABO blood group and rhesus D factor.
If the patient is Rh positive, their cells have the Rh antigen.
If the patient is Rh negative, their cells lack the Rh antigen.
If they have prior exposure to the Rh antigen (such as from placental
bleeding with an Rh-positive infant) → patient may have developed
antibodies against Rh factor (known as sensitization or
isoimmunization)
The antibodies produced by a sensitized Rh-negative mother may
attack an Rh-positive fetus, resulting in fetal demise if not managed
appropriately.
Rh-negative individuals should be treated with anti-D immunoglobulin 300
µg IM in the following situations:[1]
At 28 wGA
Delivery of an Rh-positive newborn
Ectopic pregnancy
Pregnancy loss or induced abortion
Unexplained vaginal bleeding
Chorionic villus sampling (CVS) and amniocentesis
Abdominal trauma and/or placental abruption
The antibody screening is looking for a number of different maternal
antibodies (not just Rh D) that may attack fetal blood cells and potentially
cause fetal demise.
Rubella and varicella antibody titers:
Nonimmune individuals are at risk for giving birth to a baby with congenital
rubella or varicella syndromes.
Rubella and varicella vaccines are contraindicated in pregnancy.
Nonimmune women should be counseled to avoid sick people and to be
vaccinated after pregnancy.
Pregnant women exposed to varicella can be treated with immunoglobulin.
Hepatitis B surface antigen (HBsAg) serology screening:[8]
If HBsAg-positive:
Confirm with hepatitis B surface antibody (HBsAb), which will not
coexist with HBsAg in chronic carrier states (i.e., HBsAb will be
negative in chronic carrier states).
Check hepatitis B core antibody (HBcAb), which appears during the
initial infection and remains positive for life.
Refer to specialist for treatment.
Antivirals may be indicated, depending on viral load.
If HBsAg-positive, the newborn should be given the vaccine for hepatitis B
virus (HBV) and immunoglobulin upon birth to ↓ risk of vertical transmission.
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[17]
Hepatitis C screening:
Recommended in all pregnant women (for each pregnancy)
Hepatitis C antibody screening with reflex RNA testing recommended
HIV test:
High risk of vertical transmission to the infant in poorly controlled HIV/AIDS
Patients should be managed with antiretroviral therapy.
Rapid plasma reagin (screening test for syphilis):
If the test is positive, syphilis should be confirmed with a VDRL or
treponemal test.
Vertical transmission is associated with a high incidence of neonatal
mortality and morbidity.
Nonimmune hydrops fetalis
Fetal growth restriction
Skeletal abnormalities
Pneumonia
CNS symptoms
Treat with penicillin.
Chlamydia and gonorrhea nucleic acid amplification tests (NAAT)
All pregnant women < 25 years of age should be tested.
Test pregnant women > 25 years of age with risk factors for STIs.
STIs ↑ risk for:
Preterm labor/delivery (infections make the uterus “irritable”)
Neonatal infection
If positive in the 1st trimester, repeat testing in 3‒6 months, preferably in the
3rd trimester.
Note: This is not a test of cure, but rather a test for repeat infection.
Urinalysis and urine culture
Screen for proteinuria and asymptomatic bacteriuria.
Patients are at increased risk for ascending urinary tract infections (UTIs)
(e.g., pyelonephritis) in pregnancy.
Pap smear
Only if indicated by routine screening guidelines
TB skin test
In high-risk situations, such as close contact with someone infected with TB
or if infected with HIV
Initial visit interventions and counseling[1‒4]
Supplementation:
Initiate folic acid supplementation:
Generally at least 400 mcg daily
Taken 1 month before and during pregnancy can help prevent neural tube
defects
Prenatal vitamins: typically include both folic acid and iron to prevent anemia
Warning signs:
Patients should be advised to seek medical attention for:
Bleeding
Cramping/pelvic pain
Subsequent Prenatal Visits

After the initial prenatal visit, the regular schedule for otherwise healthy pregnant
women 18–35 years old should be monthly until 28 wGA, bimonthly from 28–36
wGA, and weekly from 36 wGA until delivery.
Assessment[1,3,4]
At every visit:
Maternal weight
Blood pressure
Document FHR with auscultation or ultrasound
Starting at 20 weeks: fundal height (FH) measurement
FH should be approximately equal in centimeters to their gestational age in
weeks (+/- 3 cm).
FH should continue to grow each visit.
Inappropriate FH measurements should prompt further evaluation with an
ultrasound to measure:
Fetal growth
Fluid levels
Starting around 28 weeks: fetal movement (FM)
Patients should be instructed to do daily fetal kick counts (FKCs).
FKCs: should feel at least 10 movements in a 2-hour time period at least
once per day
Patients who report decreased FM should be evaluated with fetal monitoring
.
Ask mother about:
Abnormal bleeding
Contraction-like or cramping abdominal pain
Abnormal loss of fluid
Graphic representation of fundal height measurements during different gestational ages (in
weeks) during pregnancy
Image by Lecturio.
Laboratory and imaging assessments and interventions

18‒22 weeks: full anatomic assessment of the fetus, placenta, and uterus/cervix[1,4]
24–28 weeks:[1,4]
Rh-negative mothers:
Repeat Rh and antibody screening.
Administer RhoGam.
Repeat CBC to look for:
Anemia
Thrombocytopenia
Glucose tolerance test (GTT):[9]
Screening for gestational diabetes mellitus (GDM)
A 50 gm 1-hour screening oral glucose tolerance test (OGTT):
Normal results are typically defined as a serum glucose level of < 130‒
140 mg/dL, measured 1 hour after a 50-g glucose load (thresholds vary
within this range).[1]
If the test is abnormal, a 3-hour OGTT should be performed to diagnose or
exclude GDM.
Four blood glucose values are obtained: fasting, then at 1, 2, and 3
hours after a 100-g oral glucose load.
GDM is diagnosed if 2 of the 4 values are abnormal.
Multiple different sets of cutoffs are used; the 2 most common are the
Carpenter and Coustan thresholds and those put forth by the National
Diabetes Data Group (see table for values).
Table: Comparison of the Carpenter and Coustan with National Diabetes Data
Group cutoff thresholds for diagnosing GDM[9]
Timing of test Carpenter and National Diabetes Data

Coustan Group
Fasting 95 mg/dL 105 mg/dL
1 hour after 100-g load 180 mg/dL 190 mg/dL
2 hours after 100-g 155 mg/dL 165 mg/dL

load
3 hours after 100-g 140 mg/dL 145 mg/dL

load
For either set of thresholds, 2 abnormal values are considered diagnostic of GDM.
28‒36 weeks:
Tdap vaccine in all patients
Rescreen for STDs in high-risk patients.
Group B streptococcal (GBS) culture:
Obtain an anovaginal culture at 35–37 wGA.
Group B streptococci (GBS) are a primary cause of neonatal sepsis.
If positive, then treat intrapartum with a penicillin.
Bedside ultrasound to assess fetal presentation (vertex/head down, or
breech/buttocks down)
Additional workup/assessments and interventions

Vaccinations recommended in pregnancy:[1,4]
Tdap: at 27‒36 wga
Influenza: at the beginning of flu season (regardless of gestational age)
Pneumococcal pneumonia: for patients with functional asplenia or prior
splenectomy
Hepatitis A, if indicated
Hepatitis B, if indicated
Antenatal fetal testing:[1,6]
Typically includes either:
Non-stress test
Biophysical profile
Modified biophysical profile (non-stress test + fluid assessment)
A partial list of indications and suggested frequency from the US Society for
Maternal-Fetal Medicine (SMFM) are reported in the table.
Table: Selected indications and frequency for antenatal fetal testing[6]
Condition Suggested frequency Suggested onset of

of surveillance testing surveillance testing
Condition Suggested frequency Suggested onset of

of surveillance testing surveillance testing
Fetal growth restriction Once or twice weekly, At diagnosis

depending on severity
Oligohydramnios Once or twice weekly At diagnosis
Polyhydramnios Once or twice weekly 32–34 weeks
History of prior stillbirth Once or twice weekly Individualized
Chronic placental abruption Once or twice weekly At diagnosis
Single umbilical artery or Once weekly 36 weeks

velamentous cord insertion
Chronic hypertension (controlled Once weekly 32 weeks

with medication)
Gestational hypertension or Twice weekly At diagnosis

preeclampsia without severe
features
Preeclampsia with severe Daily At diagnosis

features
Well-controlled GDM without Once or twice weekly 32 weeks

comorbidities
Pregestational DM, or poorly Twice weekly 32 weeks

controlled GDM
Hemoglobinopathies Individualized Individualized
Obesity: prepregnancy BMI of Weekly 37 wGA

35–39.9
Obesity: prepregnancy BMI ≥ 40 Weekly 34 wGA
Body mass index (BMI) is calculated as the weight in kilograms divided by square of the
height in meters.
Workup assessments are recommended based on common presenting
symptoms.[1]
In addition to vital signs, fetal heart rate documentation, and appropriate history,
the workup for common presenting symptoms is detailed in the table.
Table: Workup and assessment for common issues
Presenting Workup/assessment
symptom
Vaginal bleeding Speculum exam → look for source of bleeding

Ultrasonography → assess placenta
Assessment of fetal well-being (typically, non-stress test)
Labs:
CBC
Type and screen (or crossmatch)
+/– Kleihauer-Betke test
+/– Coagulation panel
Give Rhogam if Rh-negative
Loss of fluid Speculum exam → look for pooling, assess cervical dilation,
collect fluid sample
Microscopy → ferning of amniotic fluid
Ultrasonography → assess fluid level and confirm
fetal position
Assessment of fetal well-being (fetal heart tones, non-stress
test)
Contractions Collect fetal fibronectin (if preterm)

Serial digital cervical exam (if no contraindications) over 1‒2
hours
Cardiotocography
Ultrasonography → assess cervical length (if preterm) and
confirm fetal position
Decreased fetal Assessment of fetal well-being with non-stress test,

movement biophysical profile, or modified biophysical profile
Prenatal Screening for Genetic

Abnormalities
There are a number of noninvasive tests that are available to assist in prenatal
diagnosis of genetic conditions. In some cases, if screening tests are positive,
more-invasive prenatal diagnostic techniques are available to provide definite
diagnosis.
Aneuploidy screening tests[1,5]
Multiple options available

Options include different combinations of multiple serum analytes and ultrasound,
which can include:
Ultrasound measurement of the nuchal translucency
Ultrasound assessment of “soft markers” for aneuploidy (findings more
common in fetuses with aneuploidy, which adjust the overall risk); examples
include:
Echogenic intracardiac foci (e.g., calcifications)
Short femur length
Echogenic bowel
1st-trimester serum analytes:
Pregnancy-associated plasma protein A (PAPP-A)
β-hCG
2nd-trimester serum analytes:
β-hCG
Unconjugated estriol
Maternal alpha-fetoprotein (AFP) level
Inhibin A level
Cell-free fetal DNA:
A screening test analyzing fetal DNA found in maternal serum (a maternal
blood test)
Often referred to as noninvasive prenatal screening (NIPS)
Performed after 10 wGA
99% accurate
Quad screen:
2nd-trimester screening of maternal serum analytes
Gives the probability of aneuploidy
Detection rate: 81%
Serum-integrated, sequential, or contingency screening:
Serum-integrated screening (SIS):
Nuchal translucency + pregnancy-associated plasma protein A at 10‒
13 6/7 wGA, then quad screen at 15‒22 wGA
Detection rate: 96%
Sequential screening:
Nuchal translucency + pregnancy-associated plasma protein A + hCG
at 10‒13 6/7 wGA, then quad screen at 15‒22 wGA
Detection rate: 95%
Contingency screening: nuchal translucency + pregnancy-associated plasma
protein A + hCG at 10‒13 6/7 wGA
If positive → confirmatory/diagnostic testing offered
If negative → no further testing
If indeterminate → quad screen at 15‒22 wGA
Detection rate: 88%‒94%
Confirmatory diagnostic tests for aneuploidy[1,5]

If aneuploidy screening tests are abnormal, patients can be referred for more
invasive diagnostic testing, which can include:
Chorionic villus sampling (CVS):

Performed at 10–14 wGA
A needle is inserted through the maternal abdomen into the chorionic villi
and blood is drawn.
Karyotype analysis is performed on the fetal blood cells.
Amniocentesis:
Performed around 15 wGA or greater
A needle is inserted through the maternal abdomen and amniotic fluid is
aspirated.
Karyotype analysis is performed on fetal cells present in the amniotic fluid.
Risks of invasive testing:
Bleeding
Infection
Fetal loss
Isoimmunization if there is Rh discordance between mother and fetus
Types of testing available for prenatal genetic diagnosis:
Karyotype
Fluorescence in situ hybridization (FISH)
Chromosomal microarray
Molecular DNA testing
Chorionic villus sampling

Image by Lecturio.
Parental genetic carrier screening tests[1,4,5]

Some patients may be at higher risk than others for certain inherited genetic
conditions. Based on specific risk factors, typically including family history and
race/ethnicity, additional genetic screening can be offered. Most commonly, this
includes carrier screening for:
Cystic fibrosis (CF)

Sickle cell anemia
Thalassemias
Spinal muscular atrophy
Fragile X syndrome
Ashkenazi Jewish genetic panel (AJGP), which includes multiple conditions, some
of which are:
Tay-Sachs disease
Canavan disease
Gaucher disease
Familial dysautonomia
CF
Fanconi anemia (FA)
Routine Counseling
Physicians play an important role in providing women with accurate information on
how to stay safe and healthy during pregnancy.
Diet[1‒3]
Table: Safe and unsafe diet in pregnancy
Safe Unsafe
Moderate caffeine intake Excess caffeine intake (typically

Artificial sweeteners defined as > 300 mg per day)
Fish with low mercury content (shrimp, Saccharine
light canned tuna, cod, tilapia): Limit to < Unpasteurized food, especially dairy
12 oz per week. (risk of listeria)
Albacore tuna: Limit to < 6 oz per week. Fish with higher mercury contents
(swordfish, shark, king mackerel, or
raw fish)
Vitamin A > 10,000 IU daily
Weight gain[1,3]
The amount of recommended weight gain during pregnancy is based on the
patient’s prepregnancy BMI. Normal weight gain recommendations are:
Underweight (BMI < 18.5): 28–40 lbs (about 12.5–18 kg)

Normal weight (BMI 18.5–24.9) : 25–35 lbs (about 11.5–16 kg)
Overweight (BMI 25–29.9) : 15–25 lbs (about 7–11.5 kg)
Obese (BMI > 30): 11–20 lbs (about 5–9 kg)
Note: Weight loss is not recommended during pregnancy.
Exercise[1,3]
Purpose: controls weight gain, improves delivery, improves weight loss after
pregnancy
Recommendation: moderate exercise for 30 minutes on most days of the week
In general, patients can continue doing exercises they were doing before
pregnancy, at the same level of intensity (goal: maintain fitness level rather than
increasing it).
Avoid contact sports and/or activities with risk of falling or abdominal trauma (e.g.,
soccer, horseback riding, downhill skiing).
Avoid exercising in hot weather due to ↑ risks associated with dehydration (e.g.,
preterm labor)
Warning signs to terminate exercise:
Chest pain or difficulty breathing
Dizziness
Vaginal bleeding or leakage of fluid
Regular contractions
Decreased fetal movement
Muscle weakness
Contraindications to aerobic exercise:
Hemodynamically significant heart disease
Restrictive lung disease
Cervical insufficiency or cerclage
Persistent vaginal bleeding
Placenta previa in the 3rd trimester
Pregnancy-induced hypertension
Pain[3,4]
Pregnancy hormones (e.g., progesterone, relaxin) cause ligaments to stretch more

easily and ↑ water retention.
Common pains:
Pelvic pain from stretching at the pubic symphysis and sacroiliac joints →
maternity support belts can help
Round ligament pain (see below)
Foot pain
Low back pain (from shifting center of gravity)
Carpal tunnel syndrome (CTS)
Round ligament pain:
The round ligaments are ligaments attaching the uterus to the pelvic
sidewall.
As the uterus grows, these ligaments can stretch and cause pain.
Differentiating round ligament pain (benign) from more concerning pain:
Round ligament pain is often unilateral.
On exam, push the uterus toward the painful side; if this maneuver
relieves the pain, it is likely round ligament pain.
Analgesic use:
Regular exercise can help with low back and pelvic pain.
Acetaminophen is the safest analgesic.
Try to avoid NSAIDs because of their effects on the fetal kidneys.
GI symptoms
Nausea and vomiting:[10]
Common, especially in early pregnancy (colloquially, “morning sickness”)
More common in the mornings but may occur throughout the day
Often improves in the early 2nd trimester
Management:
Ginger has some evidence of benefit.
Chamomile is also recommended by the WHO.
Vitamin B6 supplementation
If symptoms persist, see table for additional options.
Dietary changes: Eat first thing in the morning, and eat smaller, more
frequent meals.
Acid reflux/heartburn:[2‒4]
Encourage diet and lifestyle changes.
Antacids can be used for refractory symptoms.
Constipation: Encourage increased fiber (e.g., wheat bran) and water
consumption.[2,3]
Table: Treatment options for routine nausea and vomiting in pregnancy[10]
1st line Medication Dosing

options
1st line Ginger 250 mg 4 times daily
2nd line Vitamin B6 10–25 mg 3–4 times daily, given with or

(pyridoxine) without doxylamine
Doxylamine 10–20 mg 3–4 times daily, given with vitamin

B6
3rd line (add Promethazine 12.5–25 mg every 4–6 hours, orally or

1 of these) rectally
Prochlorperazine 25 mg every 12 hours, rectally
Diphenhydramine 25–50 mg every 4–6 hours, orally
Dimenhydrinate 25–50 mg every 4–6 hours, orally as needed
4th line (add Ondansetron 4 mg every 8 hours, orally OR 8 mg every 12

any of hours IV with IV fluids if dehydrated
these)
Metoclopramide 5–10 mg every 6–8 hours orally or IM OR 5–

10 mg every 8 hours IV with IV fluids if
dehydrated
Promethazine 12.5–25 mg every 4–6 hours orally, rectally,

or IM OR 12.5–25 mg every 4–6 hours IV with
IV fluids if dehydrated
Safety[1]
Air travel is safe up to 36 weeks, after which risk of labor or complications on

board ↑:
Air travel should be avoided in patients with medical or obstetric conditions
that may require emergent care.
Prolonged immobilization on longer flights ↑ risk of venous thromboembolic
events → patients should be advised to:
Wear compression stockings
Move about the cabin every 1‒2 hours
Maintain adequate hydration
Deep vein thrombosis (DVT) precautions for long trips (both flights and car trips):
Compression stockings
Frequent hydration
Frequent ambulation around the plane or at rest stops (every 1–2 hours)
Seat belts:
Lap belt should be worn low on the hips, “below” the uterus.
Shoulder belt should be worn between the breasts and directed laterally to
the uterus.
Screen for intimate partner violence (IPV), which can increase during pregnancy.
Frequent hand-washing
Avoid kitty litter (to ↓ risk of toxoplasmosis)
References
1. American College of Obstetricians and Gynecologists & the American Academy of Pediatrics.
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10/8/24, 13:03 Prenatal Care (Clinical) - Lecturio

Prenatal Care (Clinical)

Last updated: March 4, 2024

Initial Prenatal Visit

Initial Prenatal Visit

History and exam

Gravidity and parity

Past medical and surgical history:[1,4,15]

Substance use disorder (may have adverse effects on fetal development):

Medication and allergies:[1,4]

A complete physical exam should be performed. Special attention should be paid

Estimation using the LMP:

Establishing the final EDD:

Table: Determining whether a pregnancy should be dated by ultrasound (rather

Gestational age Use US EDD if the discrepancy Method of US

≤ 8 6/7 weeks > 5 days CRL

9 0/7 to 13 6/7 > 7 days

14 0/7 to 15 6/7 > 7 days BPD, HC, AC, FL

16 0/7 to 21 6/7 > 10 days

22 0/7 to 27 6/7 > 14 days

≥ 28 0/7 weeks > 21 days

Ultrasound image of a 12-week fetus:

Subsequent Prenatal Visits

Laboratory and imaging assessments and interventions

Timing of test Carpenter and National Diabetes Data

Fasting 95 mg/dL 105 mg/dL

1 hour after 100-g load 180 mg/dL 190 mg/dL

2 hours after 100-g 155 mg/dL 165 mg/dL

3 hours after 100-g 140 mg/dL 145 mg/dL

Additional workup/assessments and interventions

Table: Selected indications and frequency for antenatal fetal testing[6]

Condition Suggested frequency Suggested onset of

Condition Suggested frequency Suggested onset of

Fetal growth restriction Once or twice weekly, At diagnosis

Oligohydramnios Once or twice weekly At diagnosis

Polyhydramnios Once or twice weekly 32–34 weeks

History of prior stillbirth Once or twice weekly Individualized

Chronic placental abruption Once or twice weekly At diagnosis

Single umbilical artery or Once weekly 36 weeks

Chronic hypertension (controlled Once weekly 32 weeks

Gestational hypertension or Twice weekly At diagnosis

Preeclampsia with severe Daily At diagnosis

Well-controlled GDM without Once or twice weekly 32 weeks

Pregestational DM, or poorly Twice weekly 32 weeks

Hemoglobinopathies Individualized Individualized

Obesity: prepregnancy BMI of Weekly 37 wGA

Obesity: prepregnancy BMI ≥ 40 Weekly 34 wGA

Table: Workup and assessment for common issues

Vaginal bleeding Speculum exam → look for source of bleeding

Contractions Collect fetal fibronectin (if preterm)

Decreased fetal Assessment of fetal well-being with non-stress test,

Prenatal Screening for Genetic

Aneuploidy screening tests[1,5]

Multiple options available

Confirmatory diagnostic tests for aneuploidy[1,5]

Chorionic villus sampling (CVS):

Chorionic villus sampling

Parental genetic carrier screening tests[1,4,5]

Cystic fibrosis (CF)

Moderate caffeine intake Excess caffeine intake (typically