Finding the opportunity to do preconception counseling in situations where the woman does not take the initiative to schedule a preconception visit can be difficult. Whether it is walk-in / urgent care visits, sports pre-participation examinations, or adolescent well-child exams, the following list should be "on your radar screen" to effectively avail yourself of often scarce opportunities to advise women in these preconception issues.
Preconception Health Care Checklist:
Folic acid supplement (400 mcg routine):
The USPSTF recommends that all women "planning or capable of pregnancy" take a daily supplement containing 400 - 800 mcg of folic acid.
The dose is increased for the following high-risk scenarios:
A. 1 mg in patients with diabetes or epilepsy
B. 4 mg in patients who bore a child with a previous neural tube defect
Carrier screening (ethnic background):
sickle cell anemia
Carrier screening (family history):
nonsyndromic hearing loss (connexin-26)
Screen for infectious diseases, treat, immunize, counsel
Hepatitis B immunization
Preconception immunizations (rubella, varicella)
Toxoplasmosis-avoid cat litter, garden soil, raw meat
Cytomegalovirus, parvovirus B19 (fifth disease)-frequent hand washing, universal precautions for child care and health care
Occupational exposures: Material Safety Data Sheets from employer
Household chemicals: avoid paint thinners and strippers, other solvents, pesticides
Smoking cessation: bupropion (Zyban), nicotine patches (Nicoderm)
Screen for alcoholism and use of illegal drugs
Diabetes: optimize control, folic acid, 1 mg per day, off ACE-inhibitors
Hypertension: avoid ACE inhibitors, angiotensin II receptor antagonists, thiazide diuretics
Epilepsy: optimize control; folic acid, 1 mg per day
DVT: switch from warfarin (Coumadin) to heparin
Depression/anxiety: avoid benzodiazepines
Recommend regular moderate exercise
Avoid hyperthermia (hot tubs, overheating)
Caution against obesity and being underweight
Screen for domestic violence
Assess risk of nutritional deficiencies (vegan, pica, milk intolerance, calcium or iron deficiency)
Avoid overuse of Vitamin A (recommendations are to 750 mcg (2500 IU per day) with daily upper intake limit of 3,000 mcg (10,000 IU))
Avoid overuse of Vitamin D (recommendations are 600 IU per day, tolerable upper intake is 4000 IU)
Caffeine (limit to the equivalent of two cups of coffee or six glasses of soda per day)
Note: The sugar intake in six glasses of soda is not recommended.
Amenorrhea with fatigue, nausea, and/or vomiting as well as breast changes, including tenderness, are the classic presentations of pregnancy.
Urinary frequency can also occur. Although urinary frequency can be a normal symptom of pregnancy, the possibility of a UTI in a pregnant woman should also be considered.
Softening of the cervix is known as Goodell's sign, while softening of the uterus is known as Hegar's sign.
The bluish-purple hue in the cervix and vaginal walls is known as Chadwick's sign and is caused by hyperemia.
Enlargement of the uterus can be detected by an experienced examiner as early as 8 weeks on bimanual exam. Around 12 weeks, the uterine fundus can be palpated above the symphysis pubis. Between 20 to 36 weeks of gestation, the uterine enlargement, measured in centimeters, approximates gestational age and will become a routinely elicited physical exam finding.
Fetal heart tones are typically elicited by hand-held Doppler between 10-12 weeks gestation.
Fetal movement or "quickening" is detected by the mother around 18-20 weeks of gestation.
Unfortunately, the menstrual history is not an entirely reliable indicator of pregnancy. Only 68% of pregnant adolescents report having missed a menses. Conversely, not every adolescent who misses a menses is pregnant because anovulatory cycles are normal in the early postmenarcheal years. Bleeding can occur in early pregnancy around the time of the missed menses as a result of an invasion of the trophoblast into the decidua (implantation bleed). Some adolescents mistake this bleeding for a menses, leading to a delay in diagnosis of pregnancy and potential misdating of the pregnancy. We should also remember that young women who have not yet menstruated, but are sexually active, may be at risk for pregnancy because ovulation can occasionally occur before the first menstrual period.
CBC is important to detect various nutritional and congenital anemias, and to detect platelet disorders.
Rubella immunity should be tested by assessing the presence of IgG antibodies. If the patient isn't immune, they should receive a postpartum immunization. The Rubella and the MMR vaccine is a live-virus vaccine and should not be used during pregnancy. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.)
Hepatitis B surface antigen tests for Hepatitis B, which is a major risk to the newborn. (Note: This is part of the initial prenatal laboratory workup, despite the childhood immunization history.)
Blood type to detect rhesus antibody presence. RH(D)-negative women should receive anti (D)-immune globulin to prevent hemolytic disease of the newborn.
RPR tests for syphilis, which is of particular concern during pregnancy because of the risk of transplacental infection of the fetus. Congenital infection is associated with several adverse outcomes, including:perinatal death, premature delivery, low birth weight, congenital anomalies, and active congenital syphilis in the neonate.
HIV status should be checked as the risk of perinatal transmission can be reduced from 15-40% without treatment to less than 2% with antiretroviral therapy and avoidance of breastfeeding and labor.
It is probably not necessary to test serum hCG as well as urine hCG to confirm pregnancy, in the setting of a positive urine hCG.
However, as early pregnancy urine hCG concentrations are lower than serum hCG concentrations, it is possible to have a positive serum hCG result, even with a negative urine hCG result.
Additionally, one must specify a qualitative (positive vs. negative) vs. a quantitative serum hCG. Quantitative serum hCG levels rise at a predictable rate, so serial testing of serum hCG levels can be useful to determine viability or to diagnose an ectopic pregnancy, although one measurement alone is not sufficient to accurately estimate gestational age.
An ultrasound would not be the best test to order at an early stage of pregnancy. For example, at five weeks estimated gestation, an embryo would typically not be seen. Furthermore, the results would be difficult to interpret without a serum quantitative beta human chorionic gonadotropin test (quantitative pregnancy test).
Rho(D) Immune Globulin is a critical part of modern obstetrics. Prior to the clinical use of this medication, Rh-negative mothers with Rh-positive first gestations were at high risk of having subsequent gestations and developing hemolytic anemia, hydrops, and/or fetal death. With every pregnancy, there is some passage of fetal red blood cells into the maternal circulation. This occurs at either miscarriage or delivery and can even occur in small but significant quantities across the otherwise placental barrier.
When a mother with an intact immune system detects enough of the fetal Rho-D antigen, she forms antibodies to this antigen. This immune response is usually not robust enough to impact the first gestation, but subsequent gestations are at significant risk of an immune response. When this occurs, the maternal antibodies attack the fetus' red blood cells, causing hemolytic anemia, which can lead to fetal hydrops and even fetal death.
Rho(D) Immune Globulin administered at appropriate times interrupts the maternal immunologic process. You can visualize this process by imagining the RhoGAM attaching to all of the fetal Rho-D antigenic load, making it immunologically "invisible" to the maternal immune system.
If the 50mcg dose appropriate for the first trimester is unavailable, the 300mcg dose used at 28 weeks and post-partum may be administered without consequence.
CBC: The main utility of the CBC is for the Hemoglobin / Hematocrit. The white blood cell (WBC) count is limited in its usefulness to detect infection (and thus a septic abortion) during pregnancy because most pregnant patients have a mild leukocytosis. Nevertheless, if significantly elevated, or associated with a bandemia, this test would need to be factored into the consideration of a septic abortion.
Wet mount preparation for trichomonas, as well as PCR testing for gonorrhea and chlamydia: All sexually transmitted infections can cause vaginal bleeding. These tests should be obtained in this clinical context, despite a previously normal recent result.
Progesterone: Laboratory testing for progesterone is most useful in extreme situations. If the result is >25, it is highly associated with a sustainable intrauterine pregnancy. If the result is <5, it is highly associated with an evolving miscarriage or ectopic pregnancy. Levels between 5 and 25 have minimal diagnostic value in distinguishing intrauterine from ectopic pregnancy. Algorithms for the diagnosis of ectopic pregnancy emphasizing progesterone measurements have been associated with a higher use of surgical management and often miss ectopic pregnancy since 85% of ectopic pregnancies will have a normal progesterone level. Nevertheless, the test remains valuable because of its positive and negative predictive value at the extremes of the reference range. In many labs, it is a common and quick test, which makes it frequently ordered.
Quantitative beta-human chorionic gonadotropin (quant. beta-hcg): This test has enormous significance, and when combined with the pelvic ultrasound, they are the definitive diagnostic modalities. However, in isolation, one beta-hCG can be challenging to interpret, especially without the ultrasound results. Human chorionic gonadotropin is secreted by the trophoblastic cells very early in embryonic life (day 7, post-ovulation). Additionally, testing for the beta-subunit is exquisitely sensitive (down to 5 mIU/mL) and specific (the placenta is the only normal tissue that excretes beta-hCG). By the expected date of menses, the beta-hCG is usually > or = 100 mIU/mL.
Furthermore, in a normal pregnancy, the beta-hCG approximately doubles every 48 hours for the first 6-7 weeks of gestation. However, an intrauterine pregnancy may not be conclusively detected until the quantitative beta-hCG reaches 1500-1800. To detect an intrauterine pregnancy by transabdominal ultrasound, the beta-hCG will typically be >5000 mIU/mL. In both ectopic gestations and spontaneous abortions, hCG levels are usually lower than normal and increase at less-than-normal rates during early gestation. Molar pregnancy and multiple gestations are both associated with higher-than-normal hCG levels.
Type and screen: Knowing the Rhesus status is critical, as all Rh negative women who are pregnant need to be given RhoGam during any episode of bleeding. However, this does not need to be repeated after initial type and screen, especially in a setting that does not appear that this is a major bleed. If the bleeding is of great volume, a type and screen would be warranted both for potential transfusion and for Kleihauer-Betke testing, which helps to estimate the quantitative amount of fetal hemoglobin in the maternal circulation and with dosing RhoGam.
+/- 1 week
If the EGA & EDD from the ultrasound measurements are within one week of the EGA / EDD estimated from the LNMP, today's gestational age and the due date (EGA & EDD) should not change to reflect the ultrasound calculations, as in this case.
If, however, the ultrasound measurements suggest an EGA & EDD that is greater than seven days from the EGA & EDD calculated from the LNMP (or, in some cases, if the LNMP is historically inaccurate), then the estimated gestational age today, as well as the estimated due date, should be changed to reflect the ultrasound measurements and estimates.
+/- 2 weeks
+/- 3 weeks
Fetal size cannot be used accurately to assess EGA or EDD and should not change a due date.
This is because of the response of the fetus to internal and external insults. During the 1st and 2nd trimester, many problems that develop result in pregnancy loss and/or teratogenensis. However, during the third trimester, many of fetal and maternal challenges manifest themselves in fetal growth. Two examples would be macrosomia due to gestational diabetes or intrauterine growth restriction as a part of the pre-eclampsia syndrome. Additionally, fetal size discrepancies can be either familial or idiopathic.
Since the ultrasound estimate of gestational age and due date is based on measurements of fetal size compared to a computerized nomogram, these third-trimester measurements should not be used for dating the EGA or EDD.
In the setting of an inevitable (or similarly, an incomplete) spontaneous abortion, the traditional choices for management are expectant management or surgical management.
Expectant management means watchful waiting with precautions regarding unusual amounts of bleeding or pain, or fever, and is effective in over 75% of cases in this setting. The disadvantage with this course of action is that it can take up to a month for the products of conception to be completely expelled. This timeframe might not normally be a problem, but a spontaneous abortion is usually complicated by sadness, grief, and even guilt. Expectant management can delay emotional closure. Nevertheless, this is a viable course of action.
Surgical options include dilitation and curettage (D&C), with or without vacuum aspiration, or manual or electric vacuum aspiration. These choices depend on a variety of factors, including primarily local resources and the surgeon's preference and experience. The main indication for suction D&C is unusually heavy bleeding and patient preference. The main contraindication is active pelvic infection and patient refusal.
Medical management, despite being off-label, is a useful third option that is becoming more common. The most common protocol involves the vaginal administration of 800 mcg of misoprostol (Cytotec), possibly repeated on day three. Success with this method is generally around 95%, and the time to completion is generally 3-4 days (but may take up to 2 weeks), as opposed to 2-6 weeks with expectant management.
Finally, confirming the receipt of rhesus immune globulin (RhoGam) in the Rhesus negative patient is advisable. If it was not given previously, it should now be administered.
7th Edition•ISBN: 9780323527361Julie S Snyder, Mariann M Harding 7th Edition•ISBN: 9780323402118Gary A. Thibodeau, Kevin T. Patton 7th Edition•ISBN: 9780323087896 (1 more)Julie S Snyder, Linda Lilley, Shelly Collins 11th Edition•ISBN: 9781111320102Ann Senisi Scott, Elizabeth Fong