1. Maternity Care I By: Brittany Wyger, MD (PGY-III)

2. Routine physical exam including pelvic exam at initial visit Detect reproductive tract abnormalities & screen for STI Maternal weight at all visits Height and weight at first visit to determine BMI Maternal BP at all visits Identify chronic HTN, preeclampsia or gestational hypertension Fetal HR auscultation after 10-12 weeks with doppler Used to confirm viable fetus, HR range = 110-160 Fundal height after 20 weeks Fundal height in cm should roughly equal gestational age in weeks Fetal lie by 36 weeks Abdominal palpation with Leopold maneuvers

5. Calorie intake Most women require an additional 300-400 cal per day Recommended weight gain for BMI Singleton pregnancy BMI <18.5 (underweight) — weight gain 28 to 40 lbs BMI 18.5 to 24.9 (normal weight) — weight gain 25 to 35 lbs BMI 25.0 to 29.9 (overweight) — weight gain 15 to 25 lbs BMI ≥30.0 (obese) — weight gain 11 to 20 lbs Twin pregnancy BMI <18.5 (underweight) — no recommendation due to insufficient data BMI 18.5 to 24.9 (normal weight) — weight gain 37 to 54 lbs BMI 25.0 to 29.9 (overweight) — weight gain 31 to 50 lbs BMI ≥30.0 (obese) — weight gain 25 to 42 lbs

6. Evaluation for edema >1+ pitting edema after 12 hours bed rest or weight gain of 5 lb in 1 week Occurs in 80% of pregant women and lacks specificity and sensitivity in diagnosing preeclampsia Urinalysis To evaluate for asymptomatic bacteriuria and protein Pap smear should be offered Based on age (>21) and pap history Oral exam Periodontal disease associated with increased risk of preterm birth Dietary counseling and folic acid supplementation 0.4mg daily recommended (4 weeks before conception ideally) to help prevent neural tube defects If previous fetus with NTD or family history, 4mg recommended daily

7. Physical exam and counseling on prenatal topics pertinent to current gestational age of pregnancy Urinalysis Vital signs, height and weight Doppler for fetal heart tones starting after week 10 Fundal height measurement after 20 weeks Fetal lie by Leopold maneuvers after 36 weeks (you can also do transabdominal US to confirm vertex positioning) Pelvic exam for cervical change and station after 36 weeks

8. Urine pregnancy test to confirm pregnancy Pap smear only if age >21 and not current GC/Chlamydia genprobe USPSTF recommendation (2005) If <25 years old Engaging in high risk sexual behaviors (incl those living in high prevalence areas…aka Louisiana), drug use, multiple partners, no barrier contraception, incarcerated (if positive treat with Rocephin & Zithromax respectively) Wet prep only if they complain of discharge (if trich positive treat with Flagyl) Pelvic exam Dating based on LMP (Naegle’s rule) LMP (1 st day) + 1 year – 3 months + 7 days LMP- 07/23/2014, EDD- 04/30/2015 Refer immediately for OB ultrasound to confirm gestational age (earlier the US, the more accurate the dates)

9. Prescribe prenatal vitamins, can also recommend prenatal/ OB gummy vitamin if patient does not tolerate regular prenatal vitamins Influenza vaccination (can be given in any trimester) Genetic screen/ Risk assessment If high risk OB  recommend referral to fetal- maternal medicine, Dr. Rodts-Palenik Order OB panel labs

10. CBC, CMP Urinalysis, Urine culture, UPT (treat asymptomatic bacteriuria in pregnancy) RPR (treat with Penicillin G Benthazine) HIV (antiretroviral therapy) Rubella IgG (if non-immune, vaccinate after delivery) Hepatitis B surface antigen (treatment is active and passive immunization of infant after delivery) Antibody screen ABO/Rh (if Rh- neg will need rhogam)

11. Sickle cell screen (if African-American or Caribbean descent) +/- Cystic Fibrosis screening Cervical cytology (as needed) HPV co-test <30 years of age- reflex (ASCUS) every 3 years >30 years of age- routine with pap every 5 years

12. Maternal quad screen (16 weeks) If abnormal, patient may want further testing (amniocentesis) Refer for OB ultrasound to assess fetal anatomy (18-20 weeks) and placental location

13. Gestational diabetes screen (O’Sullivan)- 1 hour GTT (50g oral glucose load) If CBS >140, recommend 3 hour GTT, if >190 skip 3hr 3 hr GTT  1 hr<180, 2hr <155, 3hr <140 Administer RhoGam if Rh negative patient (28 weeks) Repeat H&H to evaluate for anemia STI testing if increased risk Refer to OBGYN for BTL if requested by patient (they must sign consent forms several weeks in advance) Tdap vaccination (28-32 weeks)

14. Group B strep If positive, treat with intrapartum antibiotic prophylaxis (PCN) Fax records to L&D Give patient pager number or cell number if you so choose Counsel on labor & delivery preparation, where to go, who to call, signs of labor etc.

15. Induction of labor not recommened before 40 weeks If you and your patient choose induction, you must speak with Dr. Madden ahead of time and reserve a room in L&D (they usually need 1-2 days notice) L&D (318) 769-7030

16. Clinic visits recommened every 4 weeks from intial visit to 28 weeks gestation From 28-36 weeks recommend routine prenatal visits every 2 weeks After 36 weeks recommend routine prenatal visits weekly These are approximate and will change if patient is high risk OB

17. Artificial sweeteners Saccharin known to cross placenta and may remain in fetal tissue Caffeine Limit to 150-300mg per day, high dose associated with spontaneous abortion and low birth weight Dairy Avoid unpasteurized and soft cheeses (feta, brie, mexican queso), risk of Toxoplasma and Listeria Deli foods Avoid deli metas, paté and meat spread, risk of Listeria Eggs Avoid raw eggs (ceasar salad, eggnog, raw cookie dough), risk of Salmonella

18. Seafood Avoid shark, swordfish, mackerel, tilefish, tuna steaks, raw fish (sushi), shellfish Limit intake of other fish (incl canned tuna) to 12 oz per week Risk of Listeria, parasites, norovirus, organic pollutants (polychlorinated biphenyls and dioxins), high mercury levels can cause neurologic abnormalities in mother and fetus Herbal teas Avoid chamomile, licorice, peppermint, raspberry leaf Associated with uterine contraction, increased uterine blood flow, spontaneous abortion Meat Avoid undercooked meat, risk of Listeria and Toxoplasma Excessive consumption of liver products can cause Vit A toxicity Leftovers Thoroughly reheat before eating, risk of Listeria

19. Air travel Safe up to 36 weeks, long flights increased risk of DVT Consider the availability of medical resources at destination Breastfeeding Recommended as best feeding method Contraindicated in HIV, illicit drug use and certain medications Childbirth education Several childbirth classes are offered, increases maternal confidence but does not change overall birth outcomes Exercise 30 mins moderate exercise most days of the week recommended Avoid activities that put patient at risk for falls or abdominal trauma Fetal movement counts Not recommended, increases maternal anxiety Hair treatments Avoid during pregnancy, however not explicitly linked to malformation

20. Heavy metals Avoid because of potential for delayed fetal neurologic development Herbal therapies Avoid ginko, ephedra & ginseng (known to be harmful to fetus) Hot tubs/ saunas Avoid in 1 st trimester, heat exposure linked to NTD & miscarriage Labor & delivery What to do if membranes rupture, where to go, who to call, pain management plan, support system during delivery Medications & OTC Risk and benefits of medications Radiation Avoid ionizing radiation (may affect fetal thyroid development)

21. Workplace issues Prolonged standing, exposure to certain chemicals or radiation in the workplace Seat-belt use Use 3 point seatbelt with shoulder strap Sex May continue during pregnancy, contraindicated in placenta previa Solvents Avoid exposure particularly in areas without adequate ventilation, increase risk of miscarriage

22. Substance use Alcohol Screen pregnant women for alcohol use No amount of alcohol has been proven safe in pregnancy Fetal alcohol syndrome Tobacco Screen pregnant for tobacco use Offer smoking cessation counseling Increased risk of low birth weight Illicit drugs Inform pregnant women of potential adverse effects on the fetus, detoxification programs, methadone therapy in opiate addiction

23. Accurate dating as early as possible in the pregnancy is essential UPT usually positive within 1 week of missed menses Naegele’s rule LMP (1 st day) + 1 year – 3 months + 7 days Ex: April 7, 2014 = LMP EDD- January 14, 2015 Early US can accurately date the pregnancy & evaluate for multiple gestation Accurate within 4-7 days in 1 st trimester, 10-14 days in 2 nd trimester, 21 days in 3 rd trimester US performed at 18-20 weeks gestation for fetal anatomic screening

24. Risk of developing alloimmunization for an RhD negative woman carrying an RhD positive fetus is approximately 1.5% Risk reduced to 0.2% with RhoGam administration RhoGam is Rh(D) immune globulin ABO and Rh testing should be performed at initial visit Rh negative women should be given RhoGam (300mcg) at 28 weeks and again within 72 hours of delivery if infant has RhD-positive blood

25. RhoGam should also be given if risk of fetal-maternal transfusion is increased (CVS, amniocentesis, external cephalic version, abdominal trauma, bleeding in 2 nd or 3 rd trimester) Alloimmunization is uncommon before 12 weeks Threatened early spontaneous abortion  RhoGam 50mcg

26. Iron deficiency anemia Associated with increased risk of low birth weight & preterm delivery All pregnant women should be screened at initial visit and treated with supplemental iron if indicated (in addition to prenatal vitamin) Pregnant women who do not respond to iron supplementation within 4-6 weeks should be evaluated for other conditions (malabsorption, ongoing blood loss, thalassemia, other chronic diseases)

27. Most organizations recommend that all pregnant women be offered screening Invasive genetic testing should be offered to women >35 years of age Aneuploidy screening Nuchal translucency testing + serum testing (9- 11 weeks gestation) and serum testing again (15- 19 weeks gestation) If screening test is positive, offer amniocentesis (>15 weeks gestation) or chorionic villous sampling (11-13 weeks gestation)

28. Prenatal Screening Tests for Down Syndrome First trimester screening Nuchal translucency, free β-hCG, PAPPA (pregnancy associated plasma protein A), maternal age Quadruple screening (second trimester) Unconjugated estriol, α-fetoprotein, free β-hCG, inhibin A, maternal age Integrated screening (first and second trimesters) Nuchal translucency, PAPPA, α-fetoprotein, unconjugated estriol, free β-hCG/total hCG, inhibin A, maternal age **Most common reason for false positive is incorrect EGA**

29. Other screening tests offered to those with genetic risks based on family history of the patient and her partner Examples include: Cystic fibrosis Tay-sachs Canavan disease Sickle cell disease Thalassemias

30. Affect 1.5 per 1,000 pregnancies Detected by testing maternal serum alpha- fetoprotein levels (elevated MSAFP) Folic acid supplementation recommended early, ideally prior to conception Folic acid 400mcg daily before pregnancy and continued until 12 weeks gestation decreases the rate of NTD by 75% For those on anti-seizure meds Valproate or Carbamazepine  4mg folic acid per day recommended

31. Measure TSH in women with history of thyroid diease, Type-1 DM, other autoimmune diseases, family history of autoimmune diseases or any symptoms of thyroid disease Thyroid disease causes increased risk of pregnancy loss, preeclampsia, low birth weight, thyroid storm, prematurity and maternal CHF Women with hypothyroidism prior to pregnancy will need increased doses of Synthroid Goal TSH <2.5 mIU

32. Bacterial vaginosis Universal screening not recommended Rubella Screen for Rubella immunity at first visit, ideally should be before conception (when vaccination is safe) Non-immune patient’s should be given MMR postpartum, MMR is contraindicated during pregnancy but can be given during lactation Varicella Screen through maternal history Maternal varicella can cause congenital varicella syndrome (low birth weight, limb/ophthalmologic/neurologic abnormalities) and neonatal varicella Maternal shingles is not a risk (passive maternal immunity) Some evidence to support serologic testing if unknown immunity Non-immune women should receive vaccination postpartum and avoid exposure during pregnancy Varicella-zoster IG therapy may be given in the event of recent exposure

33. Asymptomatic bacteriuria >100,000 cfu of a single bacterial species, E.coli – most common Complicates 2-7% of pregnancies Screen at 11-16 weeks If patient has sickle cell trait then screen q trimester Treat to reduce risk of UTI, pyelonephritis and preterm labor Treatment of choice- Cephalexin 250mg po QID x7d (ampicillin no longer recommended due to high resistance rates) Repeat urine cx after therapy to ensure cure Influenza Vaccinate for influenza including household contacts Can be given at any time during the pregnancy Tetanus and Pertussis Vaccinate at 27-36 weeks gestation for best antibody response and passive immunity to the fetus

34. Group B Streptococcus Screen at 35-37 weeks gestation Treat with intrapartum antibiotic prophylaxis (PCN, Clindamycin (if PCN allergy and susceptible)), use vancomycin if resistant to Clinda Treatment indicated also for anyone with GBS bacteriuria at any stage of pregnancy or with unknown GBS status and risk factors including: preterm birth, ROM >18 hours or maternal fever Women with negative GBS Cx within 5 weeks of delivery do not require Abx even if risk factors develop (delivery 18 hrs, intrapartum temp>100.4)

35. Chlamydia- screening recommended Tx- Azithromycin, erythromycin, clindamycin Congenital eye infections, pneumonia, preterm birth Gonorrhea- screening based on personal or geographic risk Tx- Cefixime (Suprax), Ceftriaxone (Rocephin) Chorioamnionitis, preterm birth, low birth weight, congenital eye infections HPV Condylomata- screening not indicated Tx- cryotherapy, trichloroacetic acid Vertical transmission, self-limited, usually minor

36. Hep B- screening recommended Tx- active and passive immunization of the infant Vertical transmission HSV- screening not indicated, history should be asked Culture or PCR testing of lesions Tx- Acyclovir or Valacyclovir prophylaxis at 36 weeks for HSV history, suppressive therapy recommended 36 weeks  delivery Vertical transmission risk, c-section for patient with active lesions at delivery HIV- screening recommended Tx: Antiretroviral therapy Vertical transmission

37. Syphilis- screening recommended RPR or VDRL Tx: Penicillin G benzathine Congenital syphillis Trichomonas- screening not indicated Tx- Metronidazole (Flagyl) Preterm birth, PROM, low birth weight

38. Considered safe Amoxicillin Ampicillin Clindamycin Erythromycin Penicillin Cephalosporins Typically avoid Tetracyclines Nitrofurantoin* Sulfonamides* * Mixed evidence of potential birth defects per ACOG

39. Gestational Diabetes Complicates 2-5% of pregnancies Associated with hypertensive disorders, macrosomia, shoulder dystocia and c-section deliveries ACOG recommends screening early in pregnancy for those at risk (hx of gestational DM, obesity or known glucose intolerance) with HbA1C or fasting glucose All pregnant women should be screened at 24-28 weeks with a 1 hour GTT (50g glucose load) Abnormal 1 hour GTT should be followed by a 3 hour GTT (100g glucose load) Fasting glucose <95 1 hr GTT  1 hr 190 skip the 3hr GTT) 3 hr GTT  1 hr<180, 2hr <155, 3hr <140

40. Ectopic Pregnancy Risk factors: Previous ectopic pregnancy In utero DES exposure History of STI or infertility Current smoking Diagnosis: Abdominal pain & vaginal bleeding, approximately 7 weeks after LMP US is diagnostic test of choice (no intrauterine gestational sac) Transabdominal US: β-hcg >3500 Transvaginal US: β-hcg >1800

41. Ectopic Pregnancy Diagnostic curettage: used when β–hcg levels falling or levels are elevated and US does not show IUP If chorionic villi not detected, suspect ectopic pregnancy Decreasing β-hcg  follow hcg titers Rising or stable + mass >4cm  laparoscopy/laparotomy Rising or stable + mass <4cm  Medical treatment

42. Ectopic Pregnancy Treatment: Hemodynamically unstable  Laparotomy Stable patient/ Early diagnosis Laparoscopic salpingostomy Medical management with Methotrexate MTX contraindicated: Breastfeeding, immunodeficiency, liver disease, blood dyscrasias, acute pulmonary disease, PUD, renal disease

43. Hypertension in Pregnancy BP measured at each clinic visit Counsel patients on warning signs of preeclampsia Pts with chronic HTN or preeclampsia in previous pregnancy should have baseline urine protein Safe medications inlude: Methyldopa (Aldomet), Nifedipine (Procardia) and Labetalol (Trandate)

44. Preterm Birth Before 37 weeks gestation >500,000 preterm births annually in the US Progesterone IM weekly from 16-37 weeks gestation reduces preterm birth by 35% in women with hx of PROM or spontaneous preterm labor Very expensive and hard to find at most pharmacies Cervical cerclage may reduce risk in women with shortened cervical length with previous preterm birth

45. Posterm Pregnancy Decreased risk of perinatal death among women induced at 41 weeks vs expectant management to 42 weeks gestation Rate of meconium aspiration was lower with induction but no difference in rate of c-section delivery or operative vaginal delivery Counsel patients on risks and benefits of both options Twice weekly NST and weekly AFI testing Induction recommended if AFI <5mL or max vertical pocket <2cm at term

47. Which one of the following is a standard component of all prenatal visits? (check one) A: Breast examination B: Maternal weight measurement C: Assessment of fetal lie D: Pelvic examination

48. B: Maternal weight measurement

49. All pregnant women should be screened for which one of the following sexually transmitted infections? (check one) A: Hepatitis B virus B: Gonorrhea C: Herpes virus D: Trichomonas

50. A: Hepatitis B virus

51. Which one of the following vaccinations are safe to give during pregnancy? (check all that apply) A: Influenza B: Diptheria & Tetanus C: MMR D: Varicella E: BCG

52. A: Influenza B: Diptheria & Tetanus

53. When should a healthy pregnant patient be screened for gestational diabetes? (check one) A: 10-14 weeks gestation B: 16-20 weeks gestation C: 24-28 weeks gestation D: 30-34 weeks gestation

54. C: 24-28 weeks gestation

55. How much folic acid supplemenation is recommended for a patient with a family history of neural tube defects? (check one) A: 40mcg daily B: 400mcg daily C: 4mg daily D: 40mg daily

56. C: 4mg daily