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The initial prenatal assessment and routine prenatal care

INTRODUCTION — The major goal of prenatal care is to ensure the birth of a healthy
baby with minimal risk for the mother. There are several components involved in
achieving this objective: Early, accurate estimation of gestational age Identification of the
patient at risk for complications Ongoing evaluation of the health status of both mother
and fetus Anticipation of problems and intervention, if possible, to prevent or minimize
morbidity Patient education and communication

The percentage of pregnant women who initiate prenatal care in the first trimester is one
of the standard clinical performance measures used to assess the quality of maternal
health care. In the United States in 2006, 83 percent of pregnant women obtained prenatal
care in the first trimester, but 3.6 percent received no care or initiated prenatal care in the
third trimester [1] .

The optimal components of prenatal care have not been rigorously examined in
randomized trials [2-6] . A systematic review of observational studies and randomized
trials concluded that there was no conclusive evidence that prenatal care improved birth
outcomes [2,4] . Randomized trials have also shown that enhanced prenatal care (eg,
extra visits, health education, home visits, telephone contact, psychosocial support) did
not result in improved outcomes compared to routine prenatal care [7,8] . However, a
randomized trial in young women of low socioeconomic status demonstrated that group
prenatal care had a significant reduction in preterm birth, as well as increased patient
satisfaction and knowledge of labor, delivery, and infant care [9] .

Further, comparison of pregnancy outcomes in women who receive and do not receive
prenatal care is consistently confounded by socioeconomic and other factors that
influence access to prenatal care and maternal/perinatal outcome. In the developing
world, if prenatal care is not readily available, then adequate delivery of other health care
and social services often also are not readily available. This is important since
complications resulting in serious morbidity or mortality are most likely to occur at
delivery.

Additionally, prenatal care is not a single intervention, instead it represents a series of


assessments and interventions over time that are not uniformly applied by different
practitioners. Thus, although the "quantity" of prenatal care is relatively easy to measure
(ie, timing and number of visits adjusted for gestational age at delivery), the "quality" of
prenatal care and the effect of individual components on outcome are quite difficult to
measure.

Defining outcomes is also not straightforward as pregnancy has several measurable


maternal, fetal, and neonatal outcomes. Lastly, most studies do not possess the sample
size necessary to detect statistically significant differences in the outcomes evaluated.
The following discussion relates primarily to prenatal care in the United States. Many of
these issues are common to pregnancies worldwide. However, some issues that are highly
important in other parts of the world, such as tetanus and malaria prophylaxis, are not
discussed here, but are reviewed in detail separately. (See "Overview of malaria in
pregnancy" and see "Tetanus").

CARE PROVIDER — In the United States, midwives are the lead maternity care
providers for 8 to 9 percent of women during pregnancy and childbirth, family physicians
are the lead maternity care providers for 6 to 7 percent of women, and obstetrician-
gynecologists care for most of the remainder [34] . The different types of prenatal care
providers have been studied: A systematic review evaluated three randomized trials of
midwife/general practitioner-managed care compared to obstetrician/gynecologist-led
shared care of low risk women [3] . The clinical efficacy of the two groups was similar;
however, women favored midwife-led care and, in some countries, there was a cost
reduction if antenatal care was provided by staff other than an obstetrician/gynecologist.
Another systematic review compared clinical trials of midwife-led
antepartum/intrapartum care with other models of care and also found several benefits to
midwife-led care (eg, more natural childbirths); perinatal mortality was similar for both
groups [10] .

HISTORY AND PHYSICAL EXAMINATION — It is important to identify women at


increased risk of maternal medical complications, pregnancy complications, or fetal
abnormalities. Early identification of these women gives the provider an opportunity to
discuss these issues and their management with the patient and, in some cases,
interventions are possible that minimize the risk of an adverse outcome. Ideally, this
process is initiated prior to pregnancy during a preconception consultation [11] . (See
"Preconception evaluation and counseling").

History — At or prior to the first prenatal visit, the patient should complete a
questionnaire detailing her social, medical, and family history. This information can be
used to start an obstetrical record that will record her prenatal, intrapartum, and
postpartum course. Several paper and computerized obstetrical record forms are
commercially available for this purpose. They help to ensure complete and systematic
documentation of the pregnancy and often may be used for risk-assessment planning.

The elements of the patient history include: Personal and demographic information (show
table 1) Past obstetrical history (show table 2) Personal and family medical history (show
table 3) Past surgical history Genetic history (show table 4) Menstrual and gynecological
history (show table 5) Current pregnancy history (show table 6) Psychosocial information

The American College of Obstetricians and Gynecologists (ACOG) and the American
Medical Association guidelines on domestic violence recommend that physicians
routinely assess all pregnant women for domestic violence [12,13] . The clinician should
be aware of markers and characteristics of abuse, such as bruising, improbable injury,
depression, late prenatal care (presentation after the first trimester), missed prenatal visits,
and appointments cancelled on short notice. (See "Diagnosing, screening, and counseling
for domestic violence").

Additional psychosocial issues that should also be assessed include: whether the
pregnancy was planned or unintended, potential barriers to care (eg, communication,
transportation, child care issues, economic constraints, work schedule), whether the
patient has stable housing, her mental health and level of stress, and any use of tobacco,
alcohol, or recreational drugs [14] . Areas of concern should be identified and discussed
with the patient. This is an opportunity to provide information and, if indicated, make
suggestions for possible changes or referral.

After obtaining a complete history, a "problem list" is generated. These lists are useful for
preventing the inadvertent omission of necessary maternal or fetal monitoring and
interventions.

Estimated date of delivery — A tentative estimated date of delivery (EDD) is calculated


from the menstrual history by adding seven days to the first day of the last menstrual
period (LMP) and then subtracting three months (in women with 28 day cycles). As an
example, if the last menstrual period is February 20, then the EDD will be November 27.
If the last menstrual period is May 28, the EDD will be March 4.

Accurate dating is crucial for managing the pregnancy, especially with regard to timing
interventions and monitoring fetal growth. Sonographic estimation of the EDD is
mandatory when menses are irregular, the LMP is unknown, or in patients conceiving
while taking oral contraceptive pills. Routine use of this test appears to be useful in the
general obstetrical population, as well (see "Ultrasound examination" below).

Physical examination — A complete physical examination should be performed, with


special attention to uterine size and shape and evaluation of the adnexae. Experienced
examiners can detect a very contracted pelvis, but clinical pelvimetry is not sufficiently
reliable to identify women likely to experience labor abnormalities [3] . Baseline blood
pressure, weight, and height should be recorded as part of the examination. Calculating
body mass index (BMI) helps to identify at risk populations and enables counseling of the
amount of appropriate weight gain in pregnancy. (See "Weight gain in pregnancy").

Sonographic estimation of the EDD is also useful when there is a history of irregular
menstrual cycles or when the uterine size estimated on physical examination differs from
that predicted by menstrual dating. Some causes for a discrepancy between the actual
uterine size and that expected by LMP include uterine fibroids, uterine malposition (eg,
retroverted uterus), and multiple gestation. (See "Prenatal assessment of gestational age",
section on Clinical assessment).

Sonography is also useful for evaluating suspected adnexal masses and uterine fibroids.
(See "Overview of the evaluation and management of adnexal masses" and see
"Epidemiology, clinical manifestations, diagnosis, and natural history of uterine
leiomyomas").
In a viable pregnancy, the fetal heart usually can be heard by 9 to 12 weeks of gestation
using a Doppler instrument. Transvaginal ultrasound can visualize fetal cardiac motion as
early as 5.5 to 6.0 weeks.

LABORATORY TESTS — In the absence of diagnostic physical findings, suspected


pregnancy should be confirmed by laboratory evaluation. The standard test is the
detection of the beta-subunit of human chorionic gonadotropin (hCG) in blood or urine.
(See "Diagnosis and clinical manifestations of early pregnancy").

Routine — A standard panel of laboratory tests should be obtained on every pregnant


woman at the first prenatal visit. This panel can be augmented by additional testing of
women at risk for specific conditions (see "At-risk women" below). Repetition of tests
performed preconceptionally is unnecessary. The standard panel typically consists of:
Rhesus type and antibody screen to detect antibodies potentially causing hemolytic
disease of the newborn. Rh(D)-negative women should receive anti(D)-immune globulin,
as indicated. (See "Significance of minor red blood cell antibodies during pregnancy" and
see "Pathogenesis and prenatal diagnosis of Rhesus (Rh) alloimmunization" and see
"Prevention of Rh(D) alloimmunization"). Hematocrit or hemoglobin and mean
corpuscular volume (MCV) to detect anemia and to screen for thalassemia [15] . (See
"Nutrition in pregnancy", section on Iron). Cervical cytology. However, pregnancy is not
an indication for a change in the frequency of cervical cancer screening. (See "Screening
for cervical cancer"). Rubella immunity testing. If nonimmune, the patient should be
counseled and receive postpartum immunization. Once documentation of immunity to
rubella as a result of infection or immunization has been obtained, repeat testing is
unnecessary. (See "Rubella in pregnancy") Urinary infection testing, given pregnant
women with untreated asymptomatic bacteriuria are at high risk of developing
pyelonephritis. (See "Urinary tract infections and asymptomatic bacteriuria in
pregnancy"). Syphilis testing to prevent perinatal transmission. (See "Syphilis in
pregnancy"). Hepatitis B antigen testing to prevent perinatal transmission [36,35] . (See
"Epidemiology; transmission and prevention of hepatitis B virus infection", section on
Perinatal transmission). Chlamydia testing. The Centers for Disease Control (CDC)
recommend chlamydia screening for all pregnant women, whereas ACOG's Guidelines
for Perinatal Care recommends testing only women at high risk (eg, new or more than
one sexual partner, age less than 25 years, history of sexually transmitted diseases,
inconsistent condom use, drug use) [16,17] . The US Preventive Services Task Force
(USPSTF) recommends limiting screening to women who are 24 years or younger and
older women who are at increased risk. The National Screening Committee in the United
Kingdom also does not recommend routinely screening all pregnant women [18] .

A nucleic acid amplification test (NAAT) of an endocervical specimen is the most


sensitive diagnostic test available and also has excellent specificity. Positive tests should
be treated. (See "Genital Chlamydia trachomatis infections in women" and See
"Screening for Chlamydia trachomatis", sections on Pregnancy and see "Chlamydia
trachomatis infections in the newborn"). Thyroid function. Neurologic development may
be adversely affected in children born to mothers with hypothyroidism, while maternal
hyperthyroidism can lead to fetal and maternal complications [19,20] . (See "Treatment
and prognosis of congenital hypothyroidism" and see "Overview of thyroid disease in
pregnancy").

Professional societies (eg, ACOG [21] , Endocrine Society [22] ) have recommended
testing pregnant women for thyroid dysfunction only if they are symptomatic or have a
personal or family history of thyroid disease or a medical condition associated with
thyroid dysfunction (eg, diabetes mellitus). Some data suggest that this approach may
miss up to one-third of women with hypothyroidism [23] . For this reason, some experts
recommend universal screening for thyroid dysfunction in pregnant women or those
attempting to become pregnant [24] . However, the clinical implications of failing to
diagnosis women with subclinical hypothyroidism are unclear. (See "Overview of thyroid
disease in pregnancy", section on Screening).

Human immunodeficiency virus — ACOG supports universal HIV testing of pregnant


women early in each pregnancy using an 'opt-out' approach [25] . Advantages of
universal testing include: An informed decision can be made about continuing the
pregnancy Appropriate medical management of the woman herself can be initiated
Counseling for prevention of transmission to or identification of infected partners In the
absence of intervention, the risk of perinatal transmission is from 15 to 40 percent and
can be reduced to less than 2 percent with antiretroviral therapy and avoidance of
breastfeeding and labor [17] .

The benefit of the 'opt-out' approach over the 'opt-in' approach was illustrated in a study
that found an opt-in policy was associated with testing rates of only 50 to 60 percent in
some Canadian provinces due to patient refusal and physician failure to offer the test [26]
. On the other hand, those provinces that chose an opt-out approach achieved high rates
of testing, 95 to 100 percent. Similar success with the opt-out approach has been
described in the United States [27] .

In some areas, local law requires that patient notification, as well as a signed consent
form indicating permission for HIV testing, be obtained. The medical record should
document the patient's decision to accept or decline testing. Reasons for refusal should be
explored and testing offered at another time [17] .

Retesting in the third trimester (≤ 36 weeks of gestation) is recommended for women at


increased risk for acquiring HIV infection, in areas of high HIV prevalence, and for
women who declined testing earlier in pregnancy [25] . The basis of this recommendation
is that appropriate intervention peripartum can significantly reduce perinatal
transmission. A conventional or rapid test can be used in the third trimester. (See
"Diagnostic assays for HIV infection" and see "Counseling and obstetrical management
of the HIV-infected woman to reduce perinatal HIV transmission").

Risk factors for acquiring HIV and serologic testing are discussed in detail separately.
(See "Screening for sexually transmitted diseases").
Down syndrome screening — Down syndrome is the most common chromosome
abnormality among live born infants. All pregnant women should be offered Down
syndrome screening. While such screening can be performed in the first or second
trimester or both, first trimester screening test characteristics are better than those in the
second trimester only. (See "Overview of prenatal screening and diagnosis of Down
syndrome").

At-risk women — Additional laboratory tests commonly performed in at-risk individuals


are listed below. The health care provider should interpret the test results for the patient
and discuss options for further evaluation or management. If a disorder is diagnosed, then
the natural history of the disorder, risk of disease in offspring, and the woman's
reproductive options should be discussed [28] . An abnormal result suggesting the
presence of a heritable disorder is often an indication for referral for genetic counseling.

Testing for infection N. gonorrhea — In epidemiologic studies, risk factors for


acquisition of STDs include young age (15 to 24 years old), African-American race,
unmarried status, geographical residence in an area of high prevalence, new sex partner
in past 60 days, multiple sexual partners, history of a prior STD, illicit drug use, and
admission to correctional facility or juvenile detention center. Testing and management
of positive test results is reviewed separately. (See "Neisseria gonorrhoeae infections in
women" and see "Gonococcal infection in the newborn"). Tuberculosis — All pregnant
women from populations that are recommended to have tuberculosis screening should
have a skin test placed. At-risk populations, procedure for and interpretation of skin
testing, and management of women with positive test results are described separately.
(See "Diagnosis of latent tuberculosis infection in adults" and see "Tuberculosis in
pregnancy"). Toxoplasmosis — The two most common means of acquisition of
toxoplasmosis are via environmental exposure (contaminated cat litter boxes or soil) and
ingestion of undercooked meat from infected animals. Whether all pregnant women
should undergo serological screening for toxoplasmosis is controversial. It is a routine
practice in some areas of relatively high prevalence, such as France. (See "Toxoplasmosis
and pregnancy") Hepatitis C antibodies — Several organizations have provided
guidelines for who should be tested. Despite having reviewed similar data and including
experts, the various guidelines do not all agree, except that pregnancy alone is not an
indication for testing. A summary of recommendations from the major organizations can
be found separately. (See "Screening for and diagnostic approach to hepatitis C virus
infection"). Varicella — All pregnant women should be assessed for immunity to
varicella. Women without evidence of immunity to varicella should avoid exposure to
individuals with varicella, may be candidates for passive immunization with variZIG
during pregnancy, and are candidates for varicella vaccine postpartum [29] . (See
"Varicella-zoster virus infection in pregnancy"). Bacterial vaginosis — Screening for
bacterial vaginosis is not recommended as a routine component of prenatal care. Whether
asymptomatic women with a history of prior preterm birth should be screened and
treated, if positive, to lower the risk of recurrent preterm birth is controversial. (See
"Diagnostic approach to women with vaginal discharge or vulvovaginal symptoms",
section on Bacterial vaginosis). Herpes simplex virus — Routine screening for herpes
simplex virus (HSV) infection in asymptomatic women is generally not recommended,
but this is controversial [30] . Type-specific screening may be reasonable in
asymptomatic partners of symptomatic men [31] . (See "Genital herpes simplex virus
infection and pregnancy").

Testing for heritable disorders Red cell indices — Thalassemias occur in higher
frequency in the Mediterranean area, the Middle East, Southeast Asia, Africa, and the
Indian subcontinent. An MCV less than 80 femtoliters (fL) in the absence of iron
deficiency denotes patients at risk for alpha or beta thalassemia. A detailed description of
patients and risk, and interpretation and management of positive test results can be found
separately. (See "Prenatal testing for the hemoglobinopathies and thalassemias")
Hemoglobin electrophoresis — The structural hemoglobin variants S and C are most
common in tropical Africa but are found in the Mediterranean area, Saudi Arabia, and
Caribbean. Hemoglobin E is noted among Southeast Asians and may be the most
common structural hemoglobin disorder in the world. A detailed description of patients
and risk, and interpretation and management of positive test results can be found
separately. (See "Prenatal testing for the hemoglobinopathies and thalassemias") Patients
who are of Eastern European or Ashkenazi Jewish descent or who have a relative with
one of the genetic conditions prevalent in the Ashkenazi Jewish population should be
offered carrier screening. One of these disorders, Tay-Sachs disease, also has a higher
prevalence in individuals of Pennsylvania Dutch, Southern Louisiana Cajun, and Eastern
Quebec French Canadian descent. The diseases for which these individuals are at risk and
issues regarding screening are discussed in detail separately. (See "Prenatal screening for
genetic disease in the Ashkenazi Jewish population"). Cystic fibrosis — Information
about cystic fibrosis screening should be available to all couples. Cystic fibrosis carrier
screening especially should be offered to couples who are at increased risk because of
Caucasian, European, or Ashkenazi Jewish ancestry. Cystic fibrosis counseling and
carrier testing are discussed in detail separately. (See "Cystic fibrosis: Prenatal genetic
screening"). Serum phenylalanine level — Elevated serum phenylalanine concentration
during early pregnancy in a mother with phenylketonuria or hyperphenylalanemia can
result in phenylalanine embryopathy, which can be prevented by dietary restriction of
phenylalanine intake. (See "Overview of phenylketonuria"). Fragile X — The population
at risk includes, but is not limited to, individuals of either sex with intellectual disability,
developmental delay, or autism. (See "Prenatal screening and diagnosis for fragile X
syndrome", section on Candidates for screening).

Other potentially useful tests

Ultrasound examination — Randomized trials have shown that routine early ultrasound
examination is beneficial in an unselected population because of better estimation of
gestational age resulting in significantly reduced frequency of labor induction for
postterm pregnancy and use of tocolysis for suspected preterm labor. (See "Routine
prenatal ultrasonography as a screening tool" and see "Prenatal assessment of gestational
age").

First trimester ultrasound examination can lead to earlier detection of clinically


unsuspected fetal malformations (including aneuploidies) and earlier detection of
multiple pregnancy. These effects have not been proven to improve overall fetal outcome,
although studies have lacked power to assess for secondary outcomes. (See "Routine
prenatal ultrasonography as a screening tool").

PATIENT EDUCATION — The first prenatal visit is an appropriate time to discuss the
patient's responsibilities and the expected course of pregnancy and delivery. This
information can be provided by the physician, as well as by ancillary staff, and through
written patient handouts. Some of the information should be repeated when the issues
become more germane over the course of pregnancy.

The patient's expectations should be oriented to the course of the average pregnancy. A
more detailed discussion of the management plan should be communicated with women
who are at risk for pregnancy complications because of a maternal disorder or prior
adverse pregnancy outcome.

The following list of topics represent potential areas for patient education. All of the
topics may not be relevant for all women.

Practice issues Number and frequency of prenatal visits Routine pregnancy monitoring
(eg, maternal weight, blood pressure, uterine growth, fetal activity and heart rate, possible
ultrasound examination) How to reach the provider after business hours, coverage
arrangements, and the role of office personnel (eg, nurses, midwives) Confidentiality
issues (eg, information left on phone answering machines, use of electronic mail, and
discussions with family members). There should be an explanation of the Health
Insurance Portability and Accountability Act of 1996 (HIPAA) and how it affects the
patient (information is available at www.hhs.gov/ocr/hipaa/).

Seat belts — Pregnant women should continue wearing three-point seat belts during
pregnancy. The lap belt is placed across the hips and below the uterus; the shoulder belt
goes between the breasts and lateral to the uterus. Although there are case reports of
maternal and fetal injuries resulting from seat belt use, the overall effect is that seat belts
appear to protect mother and fetus [32] .

Vitamins, nutrition, and weight gain — A standard prenatal multivitamin with iron
satisfies the daily requirements of most pregnant women. Well-nourished women may
not need multivitamins to satisfy these daily requirements, but in the absence of a careful
evaluation by a nutritionist, it is prudent to recommend them. Folate supplements to
prevent neural tube defects are recommended prior to conception and throughout the first
trimester.

Use of vitamins and minerals, nutrition and weight gain, as well as antigen avoidance
diets and foods/supplements that should be limited or avoided (eg, fish, caffeine, excess
intake of vitamin A), are discussed in detail separately. (See "Nutrition in pregnancy" and
see "Prevention of neural tube defects").
Substance use — Maternal alcohol consumption, smoking, or use of illicit drugs can be
harmful to the fetus. Patients who have problems with substance use should be strongly
advised of the risks of this behavior and referred to cessation programs in their area. (See
"Smoking and pregnancy", see "Alcohol intake and pregnancy", and see "Substance use
in pregnancy")

Infection precautions — Some infections are potentially harmful in pregnancy and


interventions exist to minimize the risk of these infections. In general, pregnant women
should avoid contact with people with febrile illnesses that could be contagious.
Influenza — Influenza vaccination is recommended for women who will be pregnant
during the influenza season, regardless of stage of pregnancy. (See "Immunization of
pregnant women"). Toxoplasmosis (See "Toxoplasmosis and pregnancy")
Cytomegalovirus (See "Cytomegalovirus infection in pregnancy") Listeria (See
"Epidemiology and pathogenesis of Listeria monocytogenes infection") Varicella (See
"Varicella-zoster virus infection in pregnancy") Parvovirus (See "Parvovirus B19
infection during pregnancy" and see "Treatment and prevention of parvovirus B19
infection") Infections associated with pets — Women who are pregnant or planning
pregnancy should avoid contact with all rodents [33] . Precautions about handling pets
and laboratory animals are discussed in topic reviews on each animal (see topic reviews
on zoonotic infection). Foodborne infections (See "Nutrition in pregnancy" section on
Avoidance of foodborne illnesses).

Work — A woman with an uncomplicated pregnancy who is employed where there are
no greater potential hazards than those encountered in routine daily life may continue to
work without interruption until the onset of labor. However, the physical demands of the
woman's job should be considered, especially in women at higher risk of preterm
delivery. (See "Work and pregnancy").

Exercise — Healthy women with uncomplicated pregnancies should continue to exercise


during pregnancy. Issues regarding type, frequency, and duration of exercise, as well as
risks of and contraindications to exercise, are reviewed separately. (See
"Recommendations for exercise during pregnancy and the postpartum period" and see
"Anatomical and physiological changes of pregnancy and exercise").

Sexual activity — Theoretically, sexual intercourse may stimulate labor due to physical
stimulation of the lower uterine segment, endogenous release of oxytocin as a result of
orgasm, direct action of prostaglandins in semen, or increased exposure to infectious
agents. However, in the absence of pregnancy complications (eg, vaginal bleeding,
ruptured membranes), there is insufficient evidence to recommend against sexual
intercourse during pregnancy. Most studies have not shown an increased risk of preterm
labor/delivery or infectious complications (unless a sexually transmitted disease is
acquired) [37,38] .

Birth defects and genetic issues — The prevalence of birth defects of medical, surgical,
or cosmetic significance is 2 to 4 percent among live born infants and does not vary
among ethnic groups. Both genetic and environmental factors play a role in their
pathogenesis. (See "Etiology of birth defects").

The clinician should discuss the causes of congenital anomalies with the patient, assess
the specific risk for her child, review options for and limitations of prenatal diagnosis,
and decide whether additional testing and referral to a geneticist would be useful.

Use of medications — Medication use is common in pregnancy [39] . All patients should
be encouraged to contact their provider with any concerns and before taking any drugs
(prescription, over the counter, or herbal [alternative] remedies) that were not previously
approved.

Since 1975, the US Food and Drug Administration (FDA) has assigned pregnancy risk
factors to all drugs available in the United States (show table 7). Information on the use
of specific drugs in pregnancy, including the FDA risk category and pregnancy
implications, is available in the UpToDate drug database, as well as in topics that review
treatment of medical conditions in pregnant women.

Acetaminophen is a widely used drug for treatment of pain and fever, with no evidence in
humans of increased risk of pregnancy loss, congenital anomalies, or neurodevelopmental
delay [40] . The extensive use of acetaminophen by pregnant women combined with the
paucity of documented adverse effects have served to make this medication the pain
reliever and antipyretic of choice during pregnancy when drug therapy is indicated [41] .
The risks and benefits of using nonsteroidal antiinflammatory drugs for treatment of pain
or fever depend on the dose, gestational age, and duration of therapy. (See "Inhibition of
acute preterm labor" section on Cylooxygenase inhibitors).

Over-the-counter and prescription drugs for treatment of respiratory infections and


allergies are discussed in detail separately. (See "Treatment of respiratory infections in
pregnant women" and see "Recognition and management of allergic disease during
pregnancy").

Constipation and diarrhea can be managed with bulk-forming preparations containing


fiber (eg, Metamucil) and kaolin and pectin (Kaopectate), respectively. (See "Maternal
gastrointestinal tract adaptation to pregnancy").

Nausea and vomiting may be pregnancy-related, or due to other causes. Supportive care
is similar regardless of the etiology. (See "Clinical features and diagnostic evaluation of
nausea and vomiting of pregnancy (hyperemesis gravidarum and morning sickness)").

Airline travel — Most airlines allow women to fly up to 35 to 36 weeks of gestation,


although individual policies may vary. Commercial airline travel is generally safe for
women with uncomplicated pregnancies [42-45] . Fetal heart rate is not affected during
flight if the mother and fetus are healthy [43] . Although some studies have shown a trend
toward increased risk of spontaneous abortion in flight attendants [42,46] and increased
preterm birth among women who fly long durations and frequently [47] , this could be
due to not accounting for relevant differences between the study subjects and controls.

Maternal physiologic adaptations to high altitude include hemoconcentration, increased


heart rate and blood pressure, and decreased aerobic capacity with reduction of partial
oxygen pressure [43,48] . For these reasons and the lack of availability of emergency
care, certain precautions should be taken: Women with complicated pregnancies that may
be exacerated by flight conditions or require emergency care should avoid air travel [44] .
All airline travelers should maintain hydration, periodically move their lower extremities
to avoid stasis and potential venous thrombosis, and continuously wear seat belts to
protect against unexpected turbulence. Use of support stockings and avoidance of
restrictive clothing may be helpful [44] . Supplemental oxygen should be administered to
pregnant women who must travel and may not tolerate the hypoxic environment of high
altitude flying, even in pressurized aircraft (eg, women with sickle cell or cyanotic heart
disease) [44] . (See "Traveling with oxygen aboard commercial air carriers").

The amount of cosmic radiation received during airline travel is below the level at which
there begins to be concern about possible harmful fetal effects (20 millisievert or 2 rem)
[49] . As an example, a woman on a round trip transpolar flight from New York to Tokyo
would be exposed to approximately 15 mrem cosmic radiation; for a round trip
transcontinental flight across the United States, the exposure would be 6 mrem. By
comparison, the International Commission on Radiological Protection (ICRP) and the
National Council on Radiation Protection (NCRP) recommended limit for maximum
cumulative radiation exposure for a member of the general public over one year is 100
mrem [50,51] . Pilots, flight attendants, and frequent fliers might exceed this level. They
should be aware of their personal radiation exposure, which can be calculated using the
Federal Aviation Administration Radiobiological Team web site
(jag.cami.jccbi.gov./cariprofile.asp). A detailed discussion of radiation risks in pregnancy
can be found separately. (See "Diagnostic imaging procedures during pregnancy").

Travel to moderate and high altitudes — Airplane passenger cabins are usually
pressurized to an altitude of 5000 to 8000 feet (1524 to 2438 meters). The PO2 values at
these altitudes are 132 and 118 mmHg, respectively (show table 8) [48] . Pregnant
women may be exposed to altitudes in this range from other sources, such as visiting a
mountain resort or traveling in a hot air balloon or noncommercial aircraft. There is scant
literature about acute, short-term exposure of pregnant women to these moderate
altitudes. One study evaluated seven women in the third trimester at sea level (180 feet)
and then within two to four days of visiting a facility at 6000 feet (1829 m) [48] . Plasma
glucose rose from 4.53 to 5.51 mmol/L (81.6 to 99.2 mg/dL); however, maternal heart
rate, oxygen consumption, ventilation, tidal volume, and plasma catecholamine and
lactate levels did not change significantly, nor was there a change in fetal heart rate.

These data and other reports [52,53] , although limited, are reassuring that women with
uncomplicated pregnancies can tolerate acute exposure to moderate altitudes. Since an
individual's altitude tolerance cannot be reliably determined at sea level, advice on travel
to intermediate altitudes should err on the side of caution [52,53] .
High altitudes (over 8000 feet/2438 m) are more likely to cause problems. In general,
exposure of a pregnant woman to the hypoxia of high altitude results in acclimatization
responses, which preserve the fetal oxygen supply. The fetus also can utilize some
compensatory mechanisms during brief periods of hypoxia. However, these adaptive
mechanisms may not be fully compensatory in complicated pregnancies, such as those
with uteroplacental insufficiency, or at very high altitudes [54] . As an example,
pregnancy in inhabitants of Cerro de Pasco, Peru (altitude 4370 m) is associated with 31
percent lower maternal cardiac output and 11 percent lower birthweight than observed in
pregnant women residing at sea level (mean birth weight 2935 and 3290 grams,
respectively) [55] .

A survey of obstetrical care providers in Colorado reported that preterm labor and
bleeding complications of pregnancy were the most commonly encountered pregnancy
complications among pregnant visitors to high altitudes [56] . Dehydration, engaging in
strenuous exercise before acclimatization, and participation in activities with high risk of
trauma were behaviors that could increase the risk of pregnancy complications. An
altitude of 8000 feet should not be exceeded in the first few days of short-term exposure
to high altitude [52] . (See "High altitude illness: Physiology, risk factors, and general
prevention").

FOLLOW-UP VISITS — Two major goals of prenatal care in the last half of pregnancy
are diagnosis of preeclampsia and fetal malpresentation.

Routine examination at each prenatal visit typically consists of measurement of blood


pressure and weight, measurement of the uterine fundus to assess fetal growth,
auscultation of fetal heart tones, assessment of fetal activity (in the second and third
trimesters), and determination of fetal presentation (in the third trimester). These simple,
noninvasive, inexpensive procedures detect 50 percent of fetuses with growth
abnormality, prevent 70 percent of eclampsia, and uncover 80 percent of breech
presentations prior to labor [57-59] .

Urine is generally screened for protein and glucose at each visit, although the value of
these tests is questionable in women with normal blood pressure and who have been
screened for gestational diabetes [60-63] .

There is evidence from epidemiologic studies that improved detection and care of women
with hypertensive disorders of pregnancy improves outcome [62] . In addition,
randomized trials have shown that external cephalic version of the breech fetus is an
effective procedure for increasing the chance of cephalic presentation at onset of labor
and decreasing the rate of cesarean delivery (assuming vaginal breech delivery is not
desired). In contrast, clinical or sonographic suspicion of fetal growth restriction has not
been proven to improve perinatal outcome. (See "Clinical features; diagnosis; and long-
term prognosis of preeclampsia" and see "External cephalic version" and see
"Sonography" below).
Frequency of prenatal visits — There are limited data as to what constitutes the optimal
number and frequency of prenatal visits. In the United States, the minimum intervals for
prenatal visits suggested for women with uncomplicated pregnancies are every four to
five weeks until 28 weeks of gestation, every two to three weeks from 28 to 36 weeks,
and then weekly until delivery [64] . According to this schedule, a woman whose first
visit is at 6 weeks of gestation and whose last visit is at 41 weeks will have 16 prenatal
visits.

This regimen has been questioned given the cost and time constraints of modern society
and lack of proven efficacy in randomized trials [3,62,65-70] . One study randomly
allocated 2764 low risk women to traditional prenatal care (14 visits) or reduced care
(nine visits) [67] . There was no difference in any maternal or fetal outcome between
groups. Another series, which included over 24,000 women, compared pregnancy
outcome of women primarily assessed as high-risk at the first prenatal visit and who
received standard obstetrical care to women assessed as low risk who received a new
model of care (fewer clinic visits but with emphasis on interventions known to be
effective for improving maternal or neonatal outcomes) [68] . The median number of
prenatal visits in the standard and new model groups was eight and five, respectively,
with no difference in adverse pregnancy outcomes.

More frequent visits may be of benefit in monitoring women with diabetes, hypertension,
threatened preterm birth, postterm pregnancies, and other pregnancy complications.
There is no evidence that frequent visits improve pregnancy outcome in low risk
pregnancies. However, women have expressed a personal preference for more, rather
than fewer, visits [3] .

Second and third trimester laboratory tests

Screening for neural tube defects and Down syndrome — All pregnant women should be
offered screening for neural tube defects and Down syndrome (if not already performed
in the first trimester). (See "Prenatal screening and diagnosis of neural tube defects" and
see "Second trimester maternal serum screening for Down syndrome").

Gestational diabetes — Universal screening for gestational diabetes is recommended at


24 to 28 weeks of gestation. (See "Screening and diagnosis of gestational diabetes
mellitus"). Screening should also be considered in the first trimester in women with
significant risk factors (ie, obesity, prior history of gestational diabetes, prior macrosomic
infant).

Sexually transmitted disease — Testing for sexually transmitted diseases (eg, HIV [71] ,
syphilis, hepatitis B surface antigen, chlamydia, gonorrhea) should be repeated in the
third trimester in women who are at continued risk and for those who acquired a new risk
factor during pregnancy (eg, a new or more than one sex partner, evaluation or treatment
for a STD, injection of nonprescription drugs); all women under age 25 years should be
retested for Chlamydia trachomatis late in pregnancy [72] . In some areas, repeat testing
for syphilis and HIV is mandatory.
Blood count and antibody screening — A hemoglobin or hematocrit should be repeated
early in the third trimester to assess for anemia. Increased iron and folate requirements of
pregnancy may result in anemia, which can be corrected by appropriate supplementation.
Prevention of anemia may decrease the need for blood transfusion, and associated risks,
if hemorrhage occurs.

Antibody screening is repeated in unsensitized Rh(D)-negative women and anti(D)-


immune globulin administered, as indicated. Although there is good evidence that
administration of anti(D)-immune globulin is cost effective, there are no data that
establish the cost-effectiveness of repeat antibody screening at this time if the initial
antibody screen was negative. (See "Prevention of Rh(D) alloimmunization").

Group B beta-hemolytic streptococcus testing — All pregnant women should be screened


for group B beta-hemolytic streptococcus (GBS) colonization with swabs of both the
lower vagina and rectum at 35 to 37 weeks of gestation. The only patients who are
excluded from screening are those with GBS bacteriuria earlier in the current pregnancy
or those who gave birth to a previous infant with invasive GBS disease. These latter
patients are not included in the screening recommendation because they should receive
intrapartum antibiotic prophylaxis regardless of the colonization status. Intrapartum
chemoprophylaxis of colonized women has been proven to reduce the incidence of early-
onset neonatal GBS. (See "Chemoprophylaxis for the prevention of neonatal group B
streptococcal disease").

Sonography — Although early identification of growth-restricted fetuses allows for


closer surveillance and earlier intervention in case of decompensation, the use of
ultrasound in the third trimester to screen for fetal growth disturbance in low risk women
has not been effective for reliably detecting these fetuses or improving outcome. (See
"Routine prenatal ultrasonography as a screening tool").

Fetal assessment — Sonographic and cardiographic fetal assessments are indicated in


patients at-risk for fetal complications. (See "Ultrasound examination in obstetrics and
gynecology" and see "Antepartum fetal heart rate assessment" and see "The fetal
biophysical profile").

Signs and symptoms to be reported to the health care provider — These include: Vaginal
bleeding (See "Overview of the etiology and evaluation of vaginal bleeding in pregnant
women") Leakage of fluid per vagina (See "Preterm premature rupture of membranes")
Uterine contractions (See "Overview of preterm labor and delivery") Decreased fetal
activity (See "Antepartum fetal heart rate assessment") Signs of preterm labor (eg, low,
dull backache; increased uterine activity compared to previous patterns; menstrual-like
cramps; diarrhea; increased pelvic pressure; vaginal leaking of clear fluid, spotting, or
bleeding) (See "Prevention of spontaneous preterm birth")

In addition, signs or symptoms suggestive of a medical or surgical disorder should be


reported.
Second and third trimester counseling — A number of issues may be discussed in
preparation for labor and delivery. These include, but are not limited to: Route of delivery
— (See "Cesarean delivery on maternal request" and see "Trial of labor after cesarean
delivery") Management of labor — (See "Pharmacologic management of pain during
labor and delivery" and see "Preparation for labor and childbirth") Postpartum issues —
(See "Overview of postpartum care") Breast feeding — (See "Breastfeeding: Parental
education and support", sectio on Prenatal). Neonatal circumcision — (See
"Circumcision: Risks and benefits")

INFORMATION FOR PATIENTS — Educational materials on this topic are available


for patients. (See "Patient information: Avoiding infections in pregnancy" and see
"Patient information: First trimester and integrated screening for Down syndrome" and
see "Patient information: Second trimester screening for Down syndrome" see "Patient
information: Group B streptococcus and pregnancy"). We encourage you to print or e-
mail these topic reviews, or to refer patients to our public web site,
www.uptodate.com/patients, which includes these and other topics.

SUMMARY AND RECOMMENDATIONS Studies have not established that prenatal


care improves birth outcomes definitively, and it is not clear which components of
prenatal care are most effective. However, all of these studies are flawed by multiple
confounders. (See "Introduction" above and see "Frequency of prenatal visits" above and
see "Care provider" above). In low risk pregnancies, there is good evidence that
decreasing the number of prenatal visits to as few as four or five and using midwives to
provide prenatal care is cost-effective and does not adversely affect outcome. (See
"Introduction" above and see "Frequency of prenatal visits" above). There is insufficient
evidence on which to base recommendations on the optimal content of prenatal care.
However, there is good evidence for the following (See "Laboratory tests" above):

- We recommend screening for asymptomatic bacteriuria (Grade 1A). Untreated


asymptomatic bacteriuria in pregnant women often results in pyelonephritis, and
detection and treatment prevent upper tract infection and its sequelae.

- We recommend screening all pregnant women for group B beta-hemolytic


streptococcus (Grade 1A). Peripartum detection and treatment of group B beta-hemolytic
streptococcus minimizes the risk of vertical transmission. We recommend screening at-
risk women for sexually transmitted infections (Grade 1B). Treatment is indicated to
prevent horizontal and vertical transmission, as well as maternal sequelae.

- We recommend offering screening for selected fetal structural and chromosomal


abnormalities (Grade 1B). Prenatal diagnosis can detect many fetal structural and
chromosomal abnormalities. Determining women at risk of having offspring with these
abnormalities allows them additional options for evaluation and management of these
conditions.
- We recommend administration of anti(D)-immune globulin to women at risk of
alloimmunization (Grade 1A). Prophylactic anti(D)-immune globulin administration
reduces the risk of hemolytic disease of the newborn.

- We recommend screening for preeclampsia (Grade 1B) and fetal malpresentation


(Grade 1A). Recognition of preeclampsia and appropriate intervention improve outcome;
recognition of fetal malpresentation combined with external cephalic version results in
fewer cesarean deliveries in areas where vaginal breech delivery is practiced. (See
"Follow-up visits" above).