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Differential Diagnosis
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The nonpregnant uterus enlarged by myomas can be confused with the gravid uterus, but it is usually very firm and irregular An ovarian tumor may be found midline, displacing the nonpregnant uterus to the side or posteriorly Ultrasonography and a pregnancy test will provide accurate diagnosis in these circumstances
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ESSENTIALS OF PRENATAL CARE
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The first prenatal visit should occur as early as possible after the diagnosis of pregnancy and should include the following: history, physical examination, laboratory tests, advice to patients, and tests and procedures
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Manifestations of Pregnancy
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The following symptoms and signs are usually due to pregnancy, but none are diagnostic A record of the time and frequency of coitus is helpful for diagnosing and dating a pregnancy
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Ask the patient s age, ethnic background, and occupation Gather information about onset of LMP and its normality, possible conception dates, bleeding after LMP, medical history, all prior pregnancies (duration, outcome, and complications), and symptoms of present pregnancy Discuss with the patient her nutritional habits as well as any use of caffeine, tobacco, alcohol, or drugs (Table 18 1) Determine whether there is any family history of congenital anomalies and heritable diseases, a personal history of
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A Symptoms
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Amenorrhea, nausea and vomiting, breast tenderness and tingling, urinary frequency and urgency, quickening
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Copyright 2008 by The McGraw-Hill Companies, Inc Click here for terms of use
CMDT 2008
option of chorionic villus sampling or genetic amniocentesis should be offered to all women who will be 35 years of age or older at delivery and those who have had prior offspring with chromosomal abnormalities Noninvasive first trimester screening for Down syndrome by ultrasonographic nuchal translucency and serum levels of PAPP-A (pregnancy-associated plasma protein A) and free subunit of hCG can also be offered Blood screening for Tay-Sachs and Canavan disease is offered to Jewish women with Jewish partners (especially those of Ashkenazi descent), and couples of French-Canadian or Cajun ancestry should also be screened as possible Tay-Sachs carriers Screening for cystic fibrosis is offered to all pregnant women Hepatitis C antibody screening should be offered to pregnant women who are at high risk for infection Pregnant women who work in medical-dental health care or the police and fire departments and those who are household contacts of a hepatitis B virus carrier or a hemodialysis patient and are HBsAg-negative at prenatal screening are at high risk for acquiring hepatitis B They should be vaccinated during pregnancy
Table 18 1 Common drugs that are teratogenic or fetotoxic1
ACE inhibitors Alcohol Amantadine Androgens Anticonvulsants Aminoglutethimide Carbamazepine Phenytoin Valproic acid Aspirin and other salicylates (third trimester) Benzodiazepines Carbarsone (amebicide) Chloramphenicol (third trimester) Cyclophosphamide Diazoxide Diethylstilbestrol Disulfiram Ergotamine Estrogens Griseofulvin
Hypoglycemics, oral (older drugs) Isotretinoin Lithium Methotrexate Misoprostol NSAIDs (third trimester) Opioids (prolonged use) Progestins Radioiodine (antithyroid) Reserpine Ribavirin Sulfonamides (third trimester) SSRIs Tetracycline (third trimester) Thalidomide Tobacco smoking Trimethoprim (third trimester) Warfarin and other coumarin anticoagulants
Many other drugs are also contraindicated during pregnancy Evaluate any drug for its need versus its potential adverse effects Further information can be obtained from the manufacturer or from any of several teratogenic registries around the country ACE, angiotensin-converting enzyme; NSAIDs, nonsteroidal anti-inflammatory drugs; SSRIs, selective serotonin reuptake inhibitors
Advice to Patients
A Prenatal Visits
Prenatal care should begin early and maintain a schedule of regular prenatal visits: 0 28 weeks, every 4 weeks; 28 36 weeks, every 2 weeks; 36 weeks on, weekly
childhood varicella, or prior sexually transmitted diseases (STDs) or risk factors for HIV infection
B Diet
Eat a balanced diet containing the major food groups 1 Take prenatal vitamins with iron and folic acid 2 Expect to gain 20 40 lb Do not diet to lose weight during pregnancy 3 Decrease caffeine intake to 0 1 cup of coffee, tea, or caffeinated cola daily 4 Avoid eating raw or rare meat or fish suspected of elevated levels of mercury 5 Eat fresh fruits and vegetables and wash them before eating
Physical Examination
Height, weight, and blood pressure should be measured, and a general physical examination should be done Abdominal and pelvic examination should include the following: (1) estimate of uterine size or measure fundal height; (2) evaluation of bony pelvis for symmetry and adequacy; (3) evaluation of cervix for structural anatomy, infection, effacement, dilation; (4) detection of fetal heart sounds by Doppler device after 10 weeks or fetoscope after 18 weeks
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