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Prenatal Care

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Prenatal Care SFM Didactics January 7, 2003 Carol Cordy, MD Prenatal Care Evidence-based: USPSTF Recommendations (H/O) AGOG Recommendations Expert Opinion (Perinatal ... – PowerPoint PPT presentation

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Title: Prenatal Care


1
Prenatal Care
  • SFM Didactics
  • January 7, 2003
  • Carol Cordy, MD

2
Prenatal Care
  • Evidence-based
  • USPSTF Recommendations (H/O)
  • AGOG Recommendations
  • Expert Opinion (Perinatal Consult)
  • Standard of care
  • Clinic
  • Community
  • Hospital

3
Prenatal Care Cases
  • USPSTF Guidelines
  • Community Standard of Care

4
Patient 1
  • A 26 year old G2P1 from Ethiopia presents to
    your office 10 weeks from her LMP complaining of
    nausea and vaginal itching, odor and discharge.
    Her periods are regular, 28-30 days apart, and
    she is certain of her LMP. She has been married
    for 4 years and she and her husband are mutually
    monogamous.

5
Patient 1
  • The patient reports that her husband is
    hepatitis B surface antigen positive and that she
    received only one hepatitis B vaccine after her
    last pregnancy. She has never been tested for
    HIV. She and her family are planning on
    returning to Ethiopia in the next several months
    for a visit.

6
Patient 1 cont.
  • Her exam is unremarkable except for a thick,
    curdy vaginal discharge. Her uterus is enlarged
    to 12 weeks. No fetal heart tones are heard. She
    has had normal Pap's for several years, the last
    was 10 months ago.

7
Patient 1 cont.
  • What would you do next?

8
Patient 1 cont.
  • Hyphae and buds are seen on KOH prep. Clue cells
    and a positive whiff test are present on wet
    mount.
  • Routine prenatal labs are sent.
  • HIV and safe sex counseling is done.
  • HIV, a hepatitis panel and hemoglobinopathy tests
    are sent.
  • No PAP test is done.
  • Flu vaccine is administered.

9
Patient 1 cont.
  • What would you do now?

10
Patient 1 cont.
  • Treat the patient with clotrimazole PV for 7
    days and metronidazole PV for 7 days.
  • See her back in two weeks to check for fetal
    heart tones, do a urine culture, follow-up on her
    labs and do further counseling.
  • You receive labs back over the next week
    including

11
Patient 1 cont.
  • O neg , antibody screen neg
  • HgS negative
  • Rubella non-immune
  • HBsAg and HBsAb neg
  • HepC neg, HepA neg
  • HIV neg
  • Chlamydia and GC neg
  • RPR (rapid plasma reagin) NR

12
Patient 1 cont.
  • What is your plan now?

13
Patient 1 cont.
  • Make a note to
  • Check her husband for HIV and HepC.
  • Re-check antibody titers and give Rhogam at her
    28 week visit.
  • Immunize for rubella postpartum.
  • Give hepatitis A and B immunizations at her next
    visit.

14
Patient 1 cont.
  • At her next prenatal visit your patient reports
    that her nausea is worse and she is vomiting at
    least once a day. She has lost 3 pounds but is
    taking fluids without problems and urinating
    normally.
  • You hear fetal heart tones.

15
Patient 1 cont.
  • What would you do now?

16
Patient 1 cont.
  • Consider
  • B6 25-50 mg tid
  • Reglan 5-10 mg before meals
  • Other

17
Patient 1 cont.
  • The patient has a positive urine
  • culture after this visit.
  • What would you do now?

18
Patient 1 cont.
  • Treat the patient for her asymptomatic
    bacteriuria and make a note to re-culture her
    urine each trimester.
  • Consider a second trimester ultrasound if the
    patient wishes.

19
Patient 1 cont.
  • At 18 weeks the ultrasound shows that your
    patient is expecting twins.
  • You call your consulting obstetrician and
    decide to co-manage the patient for the remainder
    of her pregnancy.

20
Patient 1 cont.
  • What would you do at the
  • patients 28 week visit?

21
Patient 1 cont.
  • Antibody screen (negative)
  • Give Rhogam
  • Culture urine (negative)
  • One hour glucose tolerance test (?)
  • Check Hct (30)
  • You call your patient and have her take iron
    supplements with her prenatal vitamins

22
Patient 1 cont.
  • What would you do at the patients 36 week visit?

23
Patient 1 cont.
  • GBS
  • (positive)
  • Urine culture
  • (positive)

24
Patient 1 cont.
  • What is your plan now?

25
Patient 1 cont.
  • Treat the patients bacteriuria now and then
    treat for the remainder of her pregnancy with
    suppressive antibiotics.
  • Start antibiotics when the patient is admitted
    in active labor.
  • The patients healthy twins are delivered
    vaginally at 37 weeks by you and your friendly
    consulting obstetrician.

26
Patient 2
  • An 18 year old G2P0EAB1 presents for prenatal
    care. She has had vaginal spotting for two days
    with no cramping. She did not think she was
    pregnant until 4 weeks ago when a friend said she
    was looking fat. She did a home pregnancy test
    which was positive.

27
Patient 2 cont.
  • Your patient is not sure of her last menstrual
    period and has not been using any contraception.
    She has no regular boyfriend and is ambivalent
    about the pregnancy. The patient was treated for
    gonorrhea at the time of the EAB two years ago.
    No test of cure was done.

28
Patient 2 cont.
  • She used cocaine for one year after her EAB,
    IV heroin twice one year ago and presently smokes
    marijuana daily. She has had six sexual
    partners in the last six months.

29
Patient 2 cont.
  • She dropped out of school one year ago and
    lives on the street or with friends. He father
    is in jail and she goes home to visit her mother
    and four younger siblings if she needs money.
    She has smoked a PPD of cigarettes since she was
    13.

30
Patient 2 cont.
  • What would you do next?

31
Patient 2 cont.
  • Physical Exam
  • Height 56 Weight 108
  • Heart, lung, breast, thyroid exam normal
  • Dental caries present
  • Gums red and swollen

32
Patient 2 cont.
  • Fundus at umbilicus, FHR 140s
  • No bleeding at entroitus or cervix
  • 1 cm painless, raised, moist, pale lesion on left
    labia majora
  • Thick curdy vaginal discharge adherent to vaginal
    wall
  • Thin water discharge in posterior fornix with
    strawberry spots on the cervix

33
Patient 2 cont.
  • What infections do you suspect?
  • What would you do now?

34
Patient 2 cont.
  • Wet mount of vaginal and cervical discharge
  • Culture lesion for HSV
  • Dark field microscopy of lesion
  • Culture cervix for GC and chlamydia

35
Patient 2 cont.
  • PAP
  • Routine prenatal labs including urine culture
  • HIV counseling
  • Hepatitis panel, HIV testing
  • Start prenatal vitamins
  • Ultrasound for dates
  • Refer to teen parent support group
  • Refer to MSS and WIC and nutritionist

36
Patient 2 cont.
  • Wet mount is positive for
  • trichomoniasis and candida
  • What is your immediate treatment
  • plan?

37
Patient 2 cont.
  • Antifungal vaginal cream (avoid
  • miconazole and terconazole in first
  • trimester risk category C)
  • Metronidazole 2 gms po stat

38
Patient 2 cont.
  • Labial culture is negative for HSV
  • Cervical culture is positive for chlamydia and
    negative for gonorrhea
  • Dark field microscopy is positive for spirochetes
  • RPR (rapid plasma reagin) and FTA-ABS
    (fluorescent treponemal antibody absorption) are
    positive

39
Patient 2 cont.
  • Blood type O pos, ABS neg
  • Hct 28
  • HIV neg
  • HBsAg neg, HBsAb neg, HepC pos, Hep A neg
  • Urine culture neg
  • PAP smear neg

40
Patient 2 cont.
  • What is your treatment plan now?

41
Patient 2 cont.
  • Benzathine penicillin G 2.4 million units IM
  • Azithromycin 1 gm po stat
  • Refer for dental care
  • Give supplemental iron
  • Counsel against high-risk behavior
  • Start a plan for smoking cessation
  • Give HepA and HepB vaccines

42
Patient 2 cont.
  • Ultrasound shows normal 22 week
  • fetus, normal AFI, no evidence of
  • previa or abruption

43
Patient 2 cont.
  • What is your treatment plan?

44
Patient 2 cont.
  • Repeat syphilis serology in 3 months
  • Repeat HIV in third trimester
  • Repeat chlamydia culture in two months and wet
    prep in three weeks
  • Complete HepB and HepA vaccine series
  • Counsel against continued high-risk behavior
  • Help with smoking cessation plan

45
Patient 2 cont.
  • Follow-up testing shows
  • RPR titer reduced by 4 fold
  • Cultures and wet preps negative
  • HIV positive at 32 weeks with a
  • CD4 count of 400

46
Patient 2 cont.
  • What would you do now?

47
Patient 2 cont.
  • Begin Zidovudine 100 mg po five times per day
  • Continue counseling patient to avoid high-risk
    sexual behavior
  • Refer to HIV support group

48
Final Caveats
  • Both evidence and community standard of care need
    to be considered.
  • You cant remember everything, so have
    comprehensive, up-to-date flow sheets, look it up
    or phone a friend!
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