Updated with your comments/suggestions – thanks!
CC: prenatal care
HPI: _ is a _ y/o G_ P____ @ _ wks by _wk U/S _ CWD (consistent w. dates) who presents for prenatal care.
She currently denies: contractions, leakage of fluid, discharge, dysuria, vaginal bleeding (*placental previa (maternal blood so reactive (i.e. normal) fetal HR) vs vasa previa (fetal blood so non-reactive fetal HR)). Reports +FM (fetal mvmnt).
*NST (non-stress test: high-risk 32-34 wks or absent FM): records FHT w. spontaneous perceived fetal mvmnts; reactive (normal) if in 20 mins >2 accelerations of fetal HR >15 beats/min and lasting >15 secs. If non-reactive, vibroacoustic stimulation used to awaken fetus. Placental dysfunction leads to fetal hypoxia; to prevent CNS depression, blood is preferentially distributed to brain rather than peripheral tissue, resulting in decreased fetal activity.
LMP (last menstrual period): _
*Pregnancy dating by LMP assumes a normal 28-day cycle w. fertilization occurring on day 14; many women do not have a 28-day cycle and fertilization may occur before/after day 14. Check if consistent w. dates (CWD) by looking at 1st U/S and comparing to LMP gestational age (GA) using app “ACOG“. If the GA varies by >1 wk in the 1st T, >2 wk in the 2nd T or >3 wk in the 3rd T, go by U/S dates.
EDD (est. due date): _
*At 1 wk past-due (i.e. >41 wk), admit to L&D floor for induction
Her current issues in this pregnancy significant for:
1. N/V/Spitting (sialorrhea) in 1st T
–Prescriped Diclegis ($expensive$) -> can prescribe separate: Doxylamine (antihistamine) + pyridoxine (B6), ginger tea; Differentiate from hyperemesis gravidarum (HG) by ketonuria, serum electrolytes (hypoK+, hypoCl- metabolic alkalosis) and increased serum aminotransferases -> inpatient admission for IV antiemetics, electrolyte repletion
2. N/V/Spitting (sialorrhea) after 1st T
–Counseled likely GERD b.c progestin relaxes LES (lower esophageal sphincter) and prescribed Pepcid [famotidine]
3. Urinary frequency
–Counseled in 1st T from increased pressure of the enlarging uterus on the bladder
4. Dsyuria, +UA
–Nitrofurantoin, cephalexin, Fosfomycin, amoxicillin
5. Pyelo
–IV Abx, afebrile for 48 hrs -> PO Abx 10-14 d -> daily suppressive Abx (Nitrofurantoin, cephalexin) until 6 wks postpartu
6. White vaginal discharge
–Counseled considered normal during pregnancy -> if thick/adherent = Candida (counseled from increased estrogen levels during pregnancy) = prescribed: diflucan [fluconazole]
7. Bloating
–Prescribed simethicone
8. Varices pelvic congestion
–Prescribed anusol
9. Gestational HTN (>20 wks): mild >140/90, severe >160/110
10. DM (see below for Glucola/OGTT labs)
11. HELLP: hemolysis (uric a., LDH), elevated liver enzymes (x2 UNL), platelets (<100,000): RUQ pain (as platelets are consumed, microangiopathic hemolytic anemia (MAHA) results in thrombi to portal system & hepatocellular necrosis)
12. Preterm (37 wks) prelabor (irregular contractions, closed cervix): tocolytics (anti-contractile: indomethacin, nifedipine) c/I b.c contractions often indicate a complication (IAI, placental abruption) that requires delivery
–if >34 wks, deliver: risk of complications >> neonatal benefit
—if <34 (lung (4-word) matures at 34): steroids + latency Abx to prevent intraamniotic infection (IAI)
–if <32 wks: add Mg2+ for fetal neuroprotection
13. Hx of HSV
–Ordered antiviral prophylaxis starting at 36 wks
PNC (pre-natal care): _
PMH: _
Denies blood transfusions – accepts in case of emergencies
PSH: _
OB Hx:
_NSVD/C-sec @ _, no complications
*ask why C-sec, why premie; if PPH (postpartum hemorrhage): Sheehan’s: ant. pituitary: multiple hormone deficiencies: prolactin (failure of lactation), ACTH (adrenal insufficiency: hypotension, weight loss, lethargy), T4, amenorrhea
_TOPs (termination of pregnancy)
_SABs (spontaneous abortion)
GYN Hx:
Denies abnormal pap smears
No h/o STDs
MEDS:
Prenatal vitamins
–Counseled contains Iron, which could make constipated (docusate (stool softener) vs senna (laxative)) *if Hb<11, add more Iron
Aspirin
–Counseled for prior pre-eclampsia b.c placental dysfunction induces release of free radicals, oxidized lipids, cytokines that cause generalized endothelial dysfunction; the peroxidation of lipids activates COX and inhibits prostacyclin synthase, thus inducing rapid imbalance in the TXA2/prostacyclin ratio in favor of TXA2, which favors systemic vasoconstriction
ALLERGIES:
NKDA
FAMILY Hx:
Negative for birth defects or genetic syndromes. Negative for GYN cancer
SOCIAL Hx:
Denies ETOH/Tobacco/illicit drugs during pregnancy
Denies domestic violence/sexual/physical abuse. Safe at home
PRENATAL LABS:
1st trimester: _/_/_
CBC: WBC<Hb/Hct>Plt: _<_/_>_
–WBC increase to “reject” pregnancy
–Hb ~10 from physiologic dilution
–Cr decrease from physiologic hyperfiltration
Type (Rh) and Screen: _
Influenza:
Rubella: _
Varicella: _
Pap/HPV: _
–Pap = done at >21 q 3 yrs to detect earlier, more treatable lesions (HPV is not done b.c infection is typically cleared) -> age 30: q 5 yrs w. HPV co-testing -> age 65: can stop w. no hx and negative Paps; ask about tobacco use: lowers immune response, prevents viral clearing, thus persistent HPV & cont viral replication -> metaplastic change
Syphilis IgG: _
–1st T: dead baby, 3rd T: Saddle nose, Saber shins, Snuffles, hutchinson’S teeth; prescribed penicillin
Hepatitis B/C: _/_
HIV: _
–Scheduled C-section b.c prevents blood mixing
GC (gonorrhea)/CT (chlamydia): _/_
U/A & Urine culture: _
–U/A: protein reference range for eclampsia _; Amoxicillin for + nitrites, leukocyte esterase
–Ucx: 12-16 wks or 1st prenatal visit, if later (conditions that inflame or weaken membranes can cause preterm prelabor rupture of membranes (PPROM); intrauterine bacterial enzymatic activity can also cause contractions)
2nd Trimester: _/_/_
CBC:
–Hb nadir ~10 from physiologic dilution each trimester
if screen Rh-: Antibody _
–if -: Rhogam @ 28 wk & delivery
–if +: TCD (transcranial doppler) for fetal anemia -> PUBS (percutaneous umbilical cord sampling): confirmatory available 20>wks<34; therapeutic b.c can transfuse
DM screening
–Glucola (OGCT (oral glucose challenge test)) 24 wks: _ >140
DM diagnostic
–OGTT (oral glucose tolerance test), need 2/4: fasting, 1-hr, 2-hr, 3-hr
3rd Trimester: _/_/_
Tdap (x1 each pregnancy): _
GBS: _ *tx: Ampicillin
High-risk (<25, multiple sex partners): rescreen GC/CT _
Genetic screening:
1st T:
Sickle cell screen: _ (blacks of African descent)
CF (cystic fibrosis): _ (caucasians of European descent)
U/S (nuchal translucency, nl<3 mm), hCG, PAPP-A (pregnancy-associated plasma protein A); ~85% for Down’s
NIPT (cell-free DNA): AMA (advanced maternal age, >35 y/o) or previous hx: fetal DNA in maternal serum, >10 wks, 99% sensitivity/specificity for Down’s
2nd T:
Quad: hCG, AFP, estriol, inhibin A (mnemonic: Down’s is “Up” i.e. hCG/inhibn A “Up”, AFP is down b.c that is marker for neural tube defect); ~80% for Down’s
CF (cystic fibrosis): Caucasian of European descent
Genetic confirmatory (invasive, thus risk of abortion):
1st T:
CVS (chorionic villous sampling): *mnemonic: karaoke machines play at CVS i.e. karyotyping; available >10 wks (“early detection, early termination”)
2nd T:
Amniocentesis: *into amnion, extract fetal cells; available at >16 wks, by the time get results ~20 wks = ethical issue
OB ULTRASOUNDS:
_/_/_: _ wk _d – presentation _, placenta _, AFI _, EFW _g, overall _%, anatomy _
PHYSICAL EXAM:
VS:
Urine G/P/K: -/-/-
Gen: NAD, AAOx3
Chest: RRR
Pulm: CTAB *increase tidal volume = resp. alkalosis = pCO2 decrease, pH increaseBack: no CVA tenderness
Abd: gravid, NT/ND
Extremities: no calf tenderness
External genitalia – no external lesions noted
SSE (sterile speculum exam): normal vaginal mucosa, physiologic vaginal discharge, cervix midline w.o lesions, appears closed
FHT (fetal heart tones) >12 wks: _
FH (fundus height): _ *after ~20 wks, corresponds to # of wks
Presentation: _ by palpation
A & P
_y/o G_ P_ @ _ wks presents for prenatal care
# IUP (intra-uterine pregnancy)
– Continue PNV (prenatal vitamins)
– SAB precautions
– T1 labs ordered
– Pap/GC (gonorrhea)/CT (chlamydia) collected today
– Dating US ordered
– Flu vaccine today
OLD ABOVE——————–NEW BELOW
– Genetic screening: QUAD @ 16-20 wk
– Anatomy US @ 18 wk
– Glucola @ 24-28 wk
– Tdap @ 27 wk
– Rhogam @ 28 wk & delivery *only if Ab- (most pts are Ab+)
– T3 labs + growth US @ 32 wk
– GBS / HSV prophylaxis (if prior infection) @ 36 wk
– Delivery Plan:
– Contraceptive plan:
(1) OCPs: regular periods from placebo week; SE: breakthrough bleeding (endometrium that sheds erratically when OCP does not contain enough estrogen -> can prescribe higher estrogen content to stabilize endometrium), VTE, HTN, increased estrogen levels: candidiasis, cervical ca., breast ca. while decreasing ovarian ca., endometrial ca. (b.c progestin component suppresses endometrial proliferation); c/I in migraine w. aura, VTE, HTN, liver dz (hepatic adenoma)
(2) levonorgestrel (a progestin) IUD: q 5 yrs; SE: 3-6 mos of irregular bleeding due to gradual endometrial thinning (progestin-induced atrophy) followed by amenorrhea, can be used to improve anemia or AUB (abnormal uterine bleeding)
(3) copper IUD: most effective emergency contraceptive; SE: heavy menses, c/I if anemia
(4) IM depot medroxyprogesterone acetate (DMPA): q 3 mos via inhibiting GnRH (hypothalamus), thus suppressing ovulation; SE: weight gain, delayed return to fertility
(5) subdermal progestin implant: q 3 years; SE: irregular bleeding, weight gain
(6) EC (emergency contraceptive):
(i) oral levonorgestrel [Plan B]: available OTC but costs ~$50, insurance should cover w. script b.c sperm can live up to 5 days (120 hrs), so if not ovulated yet will prevent
(ii) ulipristal [ella]: just as effective on the 5th day as it is on the 1st, requires script
Dispo: RTC (return to clinic) _ wks