UBC Objectives: Maternity Care, Priority Topic: Gender Specific Issues & Priority Topic: Pregnancy

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Provide appropriate prenatal care (using standardized provincial prenatal forms and guidelines) including education regarding pregnancy progression and symptoms/signs requiring prompt medical attention
• Counsel patients regarding prenatal screening options and pathways
  

Gender Specific Issues

Key Feature 2: As part of caring for women with health concerns, assess the possible contribution of domestic violence.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Pregnancy

Key Feature 4a: In a patient presenting with a confirmed pregnancy for the first encounter: Assess maternal risk factors (medical and social).
Skill: Clinical Reasoning, Patient Centered
Phase: Hypothesis generation, History

Key Feature 4b: In a patient presenting with a confirmed pregnancy for the first encounter: Establish accurate dates.
Skill: Clinical Reasoning
​Phase: Diagnosis

Key Feature 4b: In a patient presenting with a confirmed pregnancy for the first encounter: Advise the patient about ongoing care. 
Skill: Clinical Reasoning
​Phase: Treatment

So my 42 year old confirmed primp (confirmed with the handy dandy urine beta-hCG dipstick in office) wanted to go ahead with growing this baby. What next? I certainly didn't have a half hour available to go through a complete first prenatal visit at this time, but knowing well that there was now a developing embryo (or fetus) inside of this patient - one that may be exposed to risk factors that could compromise healthy development - performing an assessment of the most important risk factors was indicated now to prevent potential harm before the more comprehensive first prenatal visit. 

Information I gather to assess and mitigate serious and common risk includes history of the current pregnancy, past medical history, medication and substance review, and social history, detailed below.
​

• ​​History of current pregnancy
  • Estimated first day of the last menstrual period (LMP)
  • Whether or not the patient was using any form of contraception, and if so, if and when this was stopped. If not recently using hormonal contraceptives, were the patient's menstrual cycles regular, and if so, what was their length (to adjust EDD if cycles shorter or longer than 28 days, see below)
  • The estimated date of confinement  (EDC) also known as the estimated date of delivery (EDD) - the latter being a less sterile way of talking about someone's birthday in my opinion - can be derived using a pregnancy wheel (or the more modern app [ex: Calculate by QxMD] that does the same thing - no need to be a mathematician and use Naegele's rule).
    • For the record though, Naegele's rule is: Due date = LMP - 3 months + 1 year + 1 week (assuming 28 day cycle and 280 days of gestation). So if a woman was having regular 30 day cycles prior to conception, you would add 2 days to the estimated due date.
  • Any illness since the LMP. Characteristically you may hear the woman say she's been experiencing nausea/morning sickness, breast tenderness, fatigue, heartburn, all of which can be very normal symptoms in the early stages of pregnancy). 
    • Symptoms that would be important not to miss: general signs of infection such as fever or signs of sexually transmitted infection such as genital discharge

• Past medical history
  • Any previous pregnancies or abortions and if there were complications
  • Brief review of previously diagnosed medical conditions
• Medications/substances
  • Review medications, including over-the-counter supplements, vitamins, and herbal supplements. Stop any potentially harmful ones (err on the side of caution and look every medication up if you're unsure whether it's safe in pregnancy), and replace with safer alternatives if need be. Common harmful medications that must be avoided include ace inhibitors, nonsteroidal antiinflammatory drugs (NSAIDs), and isotretinoin.
  • Advise patient to take at least 0.4 or 1 mg of folic acid daily to reduce the risk of the infant having a neural tube defect (advise higher dose if she has given birth to a child with a neural tube defect, or if she has risk factors that include diabetes, epilepsy, using antiepileptics, or obesity). Women can usually meet at least the low dose requirements with a prenatal vitamin (make sure they check first before they purchase it), which also has the benefit of providing supplemental iron. Although many women who are pregnant may eat a well-rounded diet and have sufficient iron stores, there is typically little harm in taking a prenatal vitamin and for some women it may offer a real benefit.
  • Inquire about alcohol, tobacco, and other substance use. If actively using any drugs, encourage complete cessation and employ harm reduction strategies as indicated.
• Social history
  • Ensure patient feels safe where she lives and is free from situations of abuse (women are at increased risk of intimate partner violence in pregnancy, which is sort of mind-blowing but statistically true). To be explored more thoroughly at first prenatal visit if no obvious risk factors at this time.*

After the above historical information is gathered and you have provided guidance to reduce risk as indicated, you want to establish the EDD and gestational age (GA) as accurately as possible, which in this day and age is by dating ultrasound, to be done straight away (sonography is most accurate at establishing EDD and GA if obtained between 7 and 10 weeks of gestation, although it continues to remain more accurate to establish EDD than using LMP in a woman with regular menstrual cycles until 22 weeks of gestation (UpToDate, 2017). This is important in planning the rest of the prenatal care throughout pregnancy as many interventions need to be timed according to gestational age, and accurate establishment of dates reduces morbidity and mortality for the mom and the infant. The mom can then be advised to return for her first prenatal appointment once the results of the dating ultrasound are back. She will continue to be seen monthly after the first prenatal appointment, eventually returning for followup every two weeks (generally in the second trimester) and afterward, every week (in the third trimester). Every visit should include some routine and some unique assessments that depend on the gestational age at the time of assessment. It is always important to screen for complications and provide anticipatory guidance including what symptoms should prompt the women to seek urgent medical attention.  (Prenatal care recommendations vary regionally. For BC, see Perinatal Services BC, including this prenatal checklist for primary care providers that includes a list of the screening maneuvers and options for genetic testing to offer/provide to women according to gestational age.) If you are not providing obstetrical care, then the patient will need to be referred to an obstetrical care provider. The rest of her prenatal care then can either be with the obstetrical care provider or may consist of a dual relationship (for example, a primary care physician who does not deliver babies may assume the majority of care and only arrange transfer of routine prenatal visits after 20 weeks of gestation or so).

*Note that while pregnancy is a risk factor for domestic abuse, many women (and men) who are not pregnant live in abusive circumstances, so it is important to screen for this opportunistically when gathering a social history.