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First Prenatal

Visit
Lucas Phi, OMSIII LECOM

History

Greeks – believed exercise during
pregnancy would birth stronger warriors

Romans – believed strong movements would
induce rupture of membranes

1901 - prenatal care programs

1911 – first prenatal clinic, diagnosed and
treated preeclampsia

Goals  Identify risks and use appropriate interventions  Evaluate health status of both mother and fetus via a thorough history and physical examination  Estimate gestational age  Build rapport and educate patient .

When should the first visit be?  Ideally 6-8 weeks after missed menses  ASAP if there is no history of preconception visit .

Patient History  Demographics and personal information  Ethnicity – risk factors such as sickle cell for African American  Religion – restrictions such as denial of blood transfusion for Jehova’s Witness  Education – educational level and preferred language  Age – social issues (school or medical concerns)  Contact information .

  Menstrual history  Last menstrual period Estimated due date Estimated gestational age  Characteristics of cycle Pregnancy History  Dates of deliveries  Types of Deliveries  Type of incision  Birth weight and age of past infants  Health status of children  Complications  Premature rupture of membranes  Preterm delivery  Incompetent cervix .

 Medical History  Diabetes  Chronic hypertension  Asthma  Cardiac disease  Hemoglobinopathies  Lupus  Thyroid disorders  Chronic hepatitis  Tuberculosis  Bleeding disorders  Chronic renal disease  Thromboembolic disorders .

tobacco. Surgical History  Abdominal/orthopedic procedures  History of ectopic pregnancy  History of uterine perforation or incision  Allergies  Social History  Support system  Domestic violence  Use of caffeine. alcohol. illicit drugs  Employment .

 Nutritional status   Special diets  Diabetes  Phenylketonuria  Vegetarian Current medications  Change contraindicated medications  Ex. Warfarin for heparain  OTC  Herbal Supplements .

 Genetic screen and infection history .

emotional. Risk status evaluation  Modifiable risk factors of preterm labor  Work related exposure to infectious agents or chemicals  Infectious diseases  Hereditary disorders  OTC medications  Physical. or sexual abuse  Alcohol. tobacco. or substance abuse  Diabetes mellitus  Psychiatric disorders .

early symptoms of pregnancy  Pelvic exam Transvaginal ultrasonography – predicts viability of early pregnancies  Gestational sac seen at 5 weeks or hCG level . misuse or absence of contraception.Diagnosis of Pregnancy  >25 IU/L hCG in serum or urine  OTC pregnancy tests  History and physical exam   Amenorrhea. sexual activity.

2015 . 2014 -> July 27. October 21.Estimating Gestational Age   Naegele’s rule – used to find estimated date of confinement  First day of last menstrual period – 3 months + 1 year and 1 week  Ex.GA would be 35 weeks Ultrasound between 14-20 weeks  Used if last menstrual period is unknown or if patient has irregular cycles .

Physical Examination  BMI – find appropriate weight gain in pregnancy  BP – establish baseline. check for chronic HTN  Heart and lungs – preexisting conditions  Thyroid – hypo/hyperthyroidism  Breasts – masses  Nipple abnormalities that would affect latching .

infection  Consistency. condylomata. neoplasia. position. motion tenderness Uterus  Size. length. Pelvis    Cervix  Anomalies. contour  Masses such as fibroids Adnexa    Masses Bony pelvis  Diagonal conjugate  Ischial spines  Sacral hollow  Arch of pubic symphysis Ultrasound  Crown rump length at 7-10 weeks .

hemoglobin. hematocrit. Rh  Antibodies  Rh negative retested at 26-28 weeks  TSH  Pap smear  HIV . platelet count  Anemia or thalessemia  Syphilis  Rubella titer  Post partum immunization if negative  Hep B surface antigen  ABO.Lab Testing  WBC.

 Genetic screen  Tay-Sachs  Cystic fibrosis  Canavan disease (Ashkenazi)  α/βthalassemia  Sickle cell  Fragile X  Our clinic  Spinal muscular atrophy  Cystic fibrosis  Fragile X .

new sexual partner within 3 months. or multiple sexual partners Tuberculosis  PPD testing done in high risk areas .000 per milliliter Protein level – baseline Culture and Infections  Chlamydia and Gonorrhea (high risk patients)   <25 years of age with past history or evidence of STD. Urine test  Leukocyte esterase – asymptomatic bacteruria    Diagnosed with a urine culture >100.

chills. cramping. hematuria)  Threatened pregnancy loss (bleeding.Patient Education   General Information  Educational resources  Warning signs  Infection (fever. dysuria. passage of tissue) OTC medications  Use of acetaminophen over NSAIDS .

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macrosomia . low birth weight.8-26 BMI  25-35 lb  26.1-29 BMI  15-25 lb  Obese  15 lb  Twins  40 lb or 10-15 lb more than single gestation  First 2 trimesters are just maternal changes  Fetal growth is most rapid in the third trimester  Weight gain should occur by 20-22 weeks  Excess weight gain  Increased risk of preterm delivery. Weight gain  <19.8 BMI  30-40 lb  19.

000 mg  Vitamin B12 and folate   Hemoglobinopathy. neural tube defects Vitamin D  Most women have low levels . Diet  300kcal above baseline  (Optimal body weight in kg * 35kcal) + 300 kcal  Vitamins – not necessary if patient has a balanced diet  Folate is the exception – 800-1. antiseizure medication.

 Minerals – supplementation is not needed in healthy women  Iron is the exception. requirement of 1g  Can supplement with 30 mg  Iron deficient require 60-120 mg  Also require 15 mg zinc and 2mg copper  Zinc – protects against intrauterine infection  Iodine  Caffeine – increased risk of miscarriage with >200mg/day (1-2 cups)  Seafood – limit to two servings per week of canned tuna. or shrimp  Avoid fish on higher tier of food chain . salmon.

diarrhea. gas – progesterone relaxes intestinal smooth muscle  Nausea and vomiting – also known as “morning sickness”  Starts week 6-8 and peaks at weeks 12-14  Eat ginger as well as smaller meals. Exercise – encouraged ≥ 30 minutes a day  Low impact  Deep breathing may be difficult  Stop if fatigued or dizzy  Heartburn – enlarging uterus displaces stomach above esophageal sphincter  Constipation. avoid spicy food .

GERD. physical discomfort  Restless leg syndrome. rest often. or unilateral groin pain  Pain remits by patient on both hands and knees with buttocks in the air . caused by iron deficiency Backache – hyperlordosis  Minimize standing time. and take acetaminophen  Exercises that help strengthen back and abdomen  Headaches – not uncommon during first trimester  Round ligament pain  Sharp bilateral.  Sleep disturbances  Nocturia.

or elevated stress and anxiety Sexual Activity  Not restricted  Deep penetration may be more uncomfortable  Contraindication of membrane rupture and placenta previa   Forceful induction of air into vagina can cause air embolism Employment  Avoid trauma  Avoid repetitive lifting or prolonged standing of >5 hours .  Emotional Changes  Increased psychological stress  May present with signs of atypical depression.

 Urinary frequency – uterus compresses the bladder  Travel   Walk for 10 minutes every 2 hours  Always use a seatbelt Immunizations and precautions  Flu .recommended  TDAP – administered in third trimester  Listeria – avoid soft cheese and deli meat  Toxoplasmosis – avoid cats and uncooked meats  Parvovirus  CMV .

Schedule next prenatal visit!  Thank you! .

and Calvin J. Print. Philadelphia. 2008. 22 June 2015." The Prenatal Record and the Initial Prenatal Visit. Web. Web.American Family Physician. Charles J. 22 June 2015. N. pag. "Prenatal Care. The Global Library of Women's Medicine.  Phalen. Print.  Gibbs. and Urania Magriples. Ronald A." . "The Global Library of Women’s Medicine. Web..  Hacker. "Initial Prenatal Assessment and First Trimester Prenatal Care. pag. 2008. 22 June 2015. 2010." Danforth's Obstetrics and Gynecology." DynaMed. .. Hobel.. 15 June 2013. Sharon T. Danforth. Ronald S." Uptodate.  "Routine Prenatal Care. Joseph C. N. 22 June 2015. Neville F. Wolters Kulwer. Web. and Ashley D. 9 June 2015. Hill. EbscoHost. "Prenatal Care.  Lockwood. Gambone." Hacker and Moore's Essentials of Obstetrics and Gynecology. 18 June 2015. Philadelphia: Lippincott Williams & Wilkins. "Over-the-Counter Medications in Pregnancy. American Family Physician.. 1 Jan. and David N.Bibliography  Black. PA: Saunders/Elsevier.