/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/cpg/,/clinical/cckm-tools/content/cpg/preventive-health/,

/clinical/cckm-tools/content/cpg/preventive-health/name-123782-en.cckm

20180236

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Clinical Practice Guidelines,Preventive Health

Prenatal Care - Adult/Pediatric - Ambulatory

Prenatal Care - Adult/Pediatric - Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Preventive Health


Prenatal Care – Adult/Pediatric – Ambulatory
Target Population: Pregnant adolescent and adult patients
Full Guideline: Prenatal Care - Adult/Pediatric - Ambulatory clinical practice guideline
Overview of Prenatal Care
History and Examination Tests and Immunizations
Counseling/Discussion
topics
G
e
s
t
a
t
i
o
n
a
l

A
g
e

Entry of
prenatal
care –
12 weeks
• Document last menstrual cycle; if
pregnancy dating unknown, offer
dating ultrasound to ideally occur
~7-8 weeks gestation
• Document pre-gravid weight
• Obtain relevant medical history
related to current pregnancy (e.g.,
hx of preterm deliveries, chronic
medical conditions)
• Obtain current medication profile
including whether or not taking
prenatal vitamin/folic acid
• Screen for depression
• Complete physical exam including
height, weight, blood pressure and
pelvic examination
• Check fetal heart rate
• Complete blood count with differential
• Urine pregnancy and screening urine culture
• Rubella antibody, IgG
• Antibody testing (i.e., ABO and Rh typing, antibody
screen)
• HIV AB/AG combo
• Chlamydia/gonorrhea screen
• Syphilis screen
• Hepatitis B screen
• Pap smear (if indicated)
• Hepatitis C screen (if indicated)
• Pregnancy dating ultrasound (if indicated)
Tests/interventions for special populations (as
indicated)
• A1c measurement
• Creatinine
• Uric acid
• AST/ALT
• Protein/creatinine ratio
• TSH, free T4
Prenatal screening tests
• Maternal cell free DNA screen/ non invasive
prenatal testing (NIPT)
• First trimester screen
Immunizations
• Influenza vaccination
• Weight gain in pregnancy
• Lifestyle considerations in
pregnancy
• Introduce/offer prenatal
screening options for
aneuploidy and carrier
screening
• Review pregnancy dating
results (if applicable)
• Follow-up
documentation/treatment
options discussion if screen
positive for depression
12-16
weeks
• Physical exam including height,
weight, blood pressure
• Check fetal heart rate
Tests/interventions for special populations (test if
indicated)
• TSH(every 4 weeks)
• Weekly progesterone administration (if history of
spontaneous preterm delivery; initiate at 16 weeks)
Prenatal screening tests
• AFP (recommended if NIPT/First trimester screen)
• Quad screen
Immunizations
• Influenza vaccination
• Review test/ultrasound
results
• Offer/discuss prenatal
screening options with
patient (e.g., AFP if had
NIPT or First Trimester
Screen)
16-22
weeks
• Physical exam including height,
weight, blood pressure and fundal
height
• Check fetal heart rate
• 20 week ultrasound (fetal anatomy)
Tests/interventions for special populations (test if
indicated)
• TSH (every 4 weeks)
• Weekly progesterone administration (if history of
spontaneous preterm delivery)
Prenatal screening tests
• AFP
• Quad screen
Immunizations
Influenza vaccination
• Review test/ultrasound
results
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.
 



History and Examination Tests and Immunizations
Counseling/Discussion
topics
G
e
s
t
a
t
i
o
n
a
l

A
g
e

22-28
weeks
• Complete physical exam including
height, weight, blood pressure and
fundal height
• Check fetal heart rate
• 50 gram oral glucose tolerance test (24-28 weeks)
• Fasting oral glucose test (as indicated)

Tests/interventions for special populations (test if
indicated)
• TSH (may stop regular assessment if patient is
stable)
• Weekly progesterone administration (if history of
spontaneous preterm delivery)

Immunizations
• Influenza vaccination
• Review test/ultrasound
results

• Discuss TOLAC with
patient (if candidate) and
refer patient to Obstetrics
to ensure informed
consent obtained in timely
manner
28-34
weeks
• Physical exam including height,
weight, blood pressure, fundal
height
• Check fetal heart rate
• Screen for depression
• Antepartum fetal surveillance (if indicated)

Tests/interventions for special populations (test if
indicated)
• TSH (check at least once ~30 weeks))
• Weekly progesterone administration (if history of
spontaneous preterm delivery)

Immunizations
• Influenza vaccination
• Tdap vaccination (27-36 weeks)
• Discuss TOLAC with
patient (if candidate) and
refer patient to Obstetrics
to ensure informed
consent obtained in timely
manner

34-38
weeks
• Physical exam including height,
weight, blood pressure, fundal
height
• Check fetal heart rate
• Screen for depression
• Group B strep culture (35-37 weeks)
• Limited ultrasound (~37 weeks, as needed for
vertex presentation confirmation)

• Antepartum fetal surveillance (if indicated)

Tests/interventions for special populations (test if
indicated)
• HIV AB/AG combo (if indicated)
• Chlamydia/gonorrhea screen (if indicated)
• Syphilis screen (if indicated; required in IL)

Immunizations
• Influenza vaccination
• Tdap vaccination (27-36 weeks)
• Offer suppressive anti-viral
therapy to patients with
recurrent genital HSV at 36
weeks or beyond
38 weeks-
delivery
• Physical exam including height,
weight, blood pressure, fundal
height
• Check fetal heart rate
• Screen for depression
• Antepartum fetal surveillance (if indicated) • Discuss potential for labor
induction with patient, as
necessary


Common Indications for Antepartum Fetal Surveillance

Diagnosis
Gestational Age
to Initiate
Testing
Frequency of testing UW Recommendation
Maternal
conditions
Advanced maternal age (age at delivery ≥
40 years)
38 weeks Once a week
Moderate evidence,
strong recommendation
Pregnancy
related
conditions
Diabetes, diet controlled 34 weeks Twice a week
Low quality evidence,
weak/conditional recommendation
Diabetes, treated with medication 32 weeks Twice a week
Low quality evidence,
weak/conditional recommendation
Chronic hypertension* 32 weeks* Twice a week*
Low quality evidence,
weak/conditional recommendation
Pregnancy-induced hypertension* At diagnosis* Twice a week*
Low quality evidence,
weak/conditional recommendation
Preeclampsia At diagnosis Twice a week
Low quality evidence,
weak/conditional recommendation
Obesity/BMI ≥ 40 32 weeks Twice a week
Low quality evidence,
weak/conditional recommendation
Post-term pregnancy ≥ 41 weeks 41 weeks Twice a week
Moderate quality evidence,
strong recommendation
* For hypertensive disorders related to pregnancy, consider monitoring with serial growth
ultrasounds monthly starting at 28 weeks gestation
Low quality evidence,
weak/conditional recommendation
Fetus
concerns
Amniotic fluid volume, oligohydramnios
(AFI < 5 cm)
At diagnosis
Discussed/determined with
maternal fetal medicine provider
Moderate quality evidence, strong
recommendation
Growth restricted fetus
28 weeks or at
diagnosis
1-2 times per week or at discretion
of maternal fetal medicine provider
Moderate quality evidence,
strong recommendation
Previous stillbirth/intrauterine fetal demise
(IUFD)
32 weeks or 2
weeks prior to
previous stillbirth
Twice a week
Moderate quality evidence,
strong recommendation
Copyright © 2018 University of Wisconsin Hospitals and Clinics Authority. All Rights Reserved. Printed with Permission.