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prenatal care

Institute of Medicine in 1999 recommends universal HIV screening during prenatal care. HIV testing is now incorporated into the routine battery of prenatal testing in some practices. Patients can still refuse testing. Laboratory: - HIV1 serology - hepatitis B serology - syphilis serology (VDRL) [6] - varicella, rubella, measles, mumps serology if immunization status unknown [27] - urinalysis for bacteriuria [6,13] - serum glucose, glucose tolerance test - carrier screening for - cystic fibrosis - cystic fibrosis genotyping - spinal muscular atrophy [17] - childhood spinal muscular atrophy genotyping - complete blood count to quantify the risks for thalassemias & hemoglobinopathies [17] - serum TSH - offspring of women with elevated serum TSH with excess risk for prematurity & neonatal respiratory distress syndrome [38] - see ARUP consult [8] Management: 1) also see pregnancy 2) pregnant women should have at least 8 prenatal care visits 3) routine screening for diabetes mellitus on 1st prenatal visit 4) ferrous sulfate 325 mg (30-60 mg Fe+2)/day during pregnancy [10,16] (WHO recommendation) 5) folic acid - folic acid 0.4 mg or more QD begun 3 months before conception can reduce risk of neural tube defects by 70% [2] - multivitamin or folic acid supplements before or during pregnancy may reduce risk of autism in offspring [28] 6) vitamin D supplementation - little effect on maternal or neonatal outcomes [19,33] - vitamin D (1000 IU QD) beginning at 14-17 weeks gestation may increase bone mineral content among infants born in winter months [20] - maternal serum 25-hydroxy vitamin D declines from 14-34 weeks gestation in women who deliver in winter & spring unless supplemented with vitamin D [20] - maternal vitamin D deficiency duing pregnancy associated with increased risk of multiple sclerosis in offspring [29,31] - 1000-2000 IU vitamin D daily for women with immediate family member with multiple sclerosis & serum 25-OH vitamin D < 20 ng/mL [31] - vitamin D supplementation during pregnancy is associated with improved neonatal outcomes [32] 7) calcium supplementation for prevention of pre-eclampsia in populations where calcium intake is low [NGC, WHO] 8) vaccinations [27] - Tdap after 20 weeks gestation (all pregnancies) [16,22,25]; 27-36 weeks of gestation [26] - dT q 4 weeks x 2 after Tdap if not previously vaccinated for tetanus [16,23] - influenza vaccine can be given any trimester [23] - influenza vaccination between 20 & 36 weeks' gestation reduces influenza in mothers & their infants (2-4% both) [24] - does not reduce influenza in infants of HIV+ mothers [24] - TdaP & influenza vaccine during pregnancy not associated with infant hospitalization or mortality [30] - measles/mumps/rubella vaccine (MMR) & varicella vaccine immediately postpartum in pregnant nonimmune women [27] - if not pregnant & nonimmune, immunize & counsel to wait 4 weeks prior to trying to conceive 9) prenatal vitamins should contain 150-200 ug of iodine/day [9] 10) ultrasound before 24 weeks' gestation is recommended to help determine gestational age & identify fetal anomalies & multiple gestation [16] - greater depth of prenatal ultrasound may be associated with increased autism risk for autism [29] 11) NIH panel recommends 300 mg/day of DHA during pregnancy [5] 12) increase levothyroxine dose in women with hypothyroidism 30-50% prior to conception or when pregnancy discovered if unplanned [13] - prenatal screening for hypothyroidism is not recommended [7] 13) USPSTF recommends screening all pregnant women for syphilis [6,34] 14) USPSTF recommends screening all pregnant women for hepatitis B [37] 15) screening for pre-eclampsia with blood-pressure at every prenatal visit [15] 16) USPSTF recommends against screening for bacterial vaginosis [39] 17) counsel women about risks associated with overweight & obesity# - set targets for gestational weight gain informed by from pre-pregnancy body mass index [14] 18) use antidepressants with caution during pregnancy a) may be associated with a 'discontinuation' syndrome* manifested by neonatal respiratory distress ... [3] b) fluoxetine may be associated with low birth weight [4] 19) prenatal docosahexaenoic acid (DHA) supplementation does not lead to improved IQ in school-aged children [18] 20) maternal or infant probiotic supplementation reduces risk for eczema in children ages <=4 years (RR=0.78) [31] 21) fish oil supplementation during pregnancy & lactation reduces risk for allergic sensitization to egg at 1 year (RR=0.69) [31] * use of tricyclic antidepressant or SSRI during late pregnancy # infant mortality is double in obese women [14] Notes: - 1/2 of pregnant women received influenza vaccine 2017-2018 [35] - 1/2 of pregant women receive Tdap [35] - 39% of women whose infants develop pertussis < 4 months of age report receiving Tdap during pregnancy [36]

Related

planned parenthood; preconception planning; preconception risk assessment pregnancy (gestation) prenatal diagnosis

General

obstetric care; maternity care

References

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  2. Journal Watch 24(10):82, 2004 Cleves MA, Hobbs CA, Collins HB, Andrews N, Smith LN, Robbins JM. Folic acid use by women receiving routine gynecologic care. Obstet Gynecol. 2004 Apr;103(4):746-53. PMID: 15051568
  3. Journal Watch 24(10):82, 2004
    1. Kallen B. Neonate characteristics after maternal use of antidepressants in late pregnancy. Arch Pediatr Adolesc Med. 2004 Apr;158(4):312-6. PMID: 15066868 - Koren G. Discontinuation syndrome following late pregnancy exposure to antidepressants. Arch Pediatr Adolesc Med. 2004 Apr;158(4):307-8. No abstract available. PMID: 15066865
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