Diagnosis Symptoms of pregnancy amenorrhea ↑ urine frequency breast engorgement nausea bluish discoloration of vagina, vulva, and cervix due to vascular congestion (Chadwick's sign) softening of cervix Urine Pregnancy Test (UPT) detects hCG or B subunit sensitive to 1-2 weeks Ultrasound most accurate method to detect fetal size gestational Sac - 5 weeks fetal image detected at 6-7 weeks cardiac activity at 8 weeks Initial Workup-First visit Estimated date of confinement (EDC) Nageles's Rule: LMP + 7 days - 3 mos + 1 yr Ex.) LMP 4/19/12, EDC = 1/26/13 calculation based on regular 28 day cycle (only 20-25%) sonogram estimation crown-rump length (CRL) biparietal diameter (BPD) of note, sonogram estimation of EDC is more accurate earlier in pregnancy than later Complete pelvic exam estimate uterine size PAP smear cultures for gonorrhea and chlamydia Labs CBC blood type with Rh status urinalysis and culture asymptomatic bacteriuria should be treated in pregnant women can progress to pyelonephritis in pregnant women due to urinary stasis and ureteral dilation (right more than left) RPR test for syphilis Rubella titer if not already immune DO NOT VACCINATE recall MMR is a live virus vaccine TB skin testing offer HIV/HBV antibody test sickle cell prep TSH hypothyroid women should have their dose of levothyroxine increased if found to be pregnant. During pregnancy, increased circulating levels of thyroxine-binding globulin (TBG) and increased plasma volume increase demand for T4 Genetic counseling indicated by history Recommend 25-35 lb weight gain during pregnancy Consider folate, iron & multivitamins First Trimester Visit every 4 weeks Evaluate weight gain / loss BP pedal edema fundal height urine dip for glucosuria and proteinuria trace glucose is normal due to ↑ GFR trace protein is not normal and should be evaluated Cell-free fetal DNA non-invasive very sensitive/specific can order at 10 weeks or greater can confirm with CVS or amniocentesis Chorionic villus sampling (CVS) definition a procedure where small samples of placenta are acquired in order to perform a prenatal genetic analysis (e.g., DNA analysis and cytogenetics) CVS is typically performed between 10 and 13 weeks of gestation indications maternal age is 35 years or older prior child had a genetic disorder (e.g., Cystic fibrosis) and chromosomal abnormalities (e.g., Down syndrome) parents are carriers of a genetic disorder first trimester ultrasound examination suggests a congenital anomaly abnormal aneuploidy screening result risks maternal alloimmunization (relative contraindication) vertical transmission of infection (e.g., HIV) complications miscarriage amniotic fluid leakage Estimate Gestational Age by Uterine Size 12 weeks At pubic symphysis 16 weeks Midway from symphysis to umbilicus 20 weeks At umbilicus 20-36 weeks Height (in cm) above pubic symphysis correlates with weeks of gestation Second Trimester Continue visits every 4 weeks 15-18 weeks offer triple marker screen (hCG, estriol, AFP) used to detect neural tube defects or trisomies 17 weeks document movement amniocentesis if > 35 years old or history indicates 24 weeks glucose screening 25 -28 weeks repeat Hct Third Trimester Every 4 weeks until week 28, then every two weeks, then every week after 36. Routine third trimester tests urine analysis blood glucose Inquire about preterm labor symptoms vaginal bleeding contractions rupture of membranes 28-30 weeks give RhoGAM if indicated 28-32 weeks mothers with pre-gestational diabetes should undergo twice weekly nonstress testing until delivery 35-37 weeks screen for Streptococcus agalactiae (Group B Strep) 36-40 weeks cervical chlamydia and gonorrhea cultures if indicated