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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 5’6’’ Weight 108# Heart, lung, breast, thyroid exam normal Dental caries present Gums red and swollen

32. Patient #2 cont. Fundus at umbilicus, FHR 140’s 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 can’t remember everything, so have comprehensive, up-to-date flow sheets, look it up or phone a friend!