Prenatal Care: First Trimester Overview
Christina C. Reed
Physical Examination
A.General assessment:
1.Vital signs.
2.Weight and height.
3.Fetal heart tones (120–160 bpm), usually heard at 13 weeks or higher.
4.Fetal movement, usually first felt between 18 and 22 weeks.
B.General appearance.
C.Thyroid:
1.Enlarged/goiter—thyroid-stimulating hormone (TSH) and free T4 and T3 labs, thyroid ultrasound (US) needed.
2.Nodules palpated—TSH and free T4 and T3 labs, thyroid US needed.
D.Breasts:
1.Symmetry.
2.Pain—breast US needed.
3.Masses—breast US needed.
4.Nipple discharge:
a.Bloody discharge—breast US needed.
E.Heart:
1.Normal auscultatory changes start in the first trimester and end 1 week after delivery:
a.Higher basal heart rate.
b.Louder heart sounds.
c.Wide splitting of S1.
d.Splitting of S2 in third trimester.
e.Systolic ejection murmur—pulmonary and tricuspid.
f.Third heart sound—most women.
g.Fourth heart sound—rare.
h.Venous hum.
i.Mammary souffle (systolic or continuous) in third trimester and postpartum in breastfeeding women.
j.Diastolic murmurs are not normal in pregnant women—consult cardiology.
F.Lungs:
1.Patients with history of asthma need high-risk consultation.
G.Abdomen:
1.Measure the fundal height after 12 weeks’ gestation.
H.Skin:
1.Dermatitis is common.
2.Scarring.
I.Extremities.
J.External genitalia:
1.Herpes outbreak present.
2.Bartholin gland enlargement.
3.Condyloma present.
K.Adnexa:
1.Enlarged—transvaginal US needed.
2.Pain—transvaginal US needed.
L.Cervix:
1.Chadwick’s sign—the cervix has a bluish hue from 6 to 8 weeks.
M.Vagina:
1.Increased vaginal discharge—white and clear are normal.
N.Rectum:
1.Hemorrhoid present.
Common Diagnostic Tests
A.Complete blood count (CBC) with platelets.
B.Rubella titer.
C.HIV fourth generation (with the patient’s consent).
D.Syphilis with reflex to TP-PA or FTA-ABS or TP-EIA (treponemal test; rapid plasma reagin [RPR] or Venereal Disease Research Laboratory [VDRL]—nontreponemal tests).
E.Hepatitis B surface antigen.
F.Blood type and Rh factor.
G.Antibody screen.
H.Urine culture and sensitivity.
I.Hemoglobin fractionation.
J.Hemoglobin A1c.
K.Cystic fibrosis and spinal muscular atrophy genetic carrier screening (with patient’s consent).
L.Tuberculosis testing, if patient has exposure to tuberculosis or symptomatic.
M.Chest x-ray, if the patient has a history of tuberculosis and/or positive purified protein derivative (PPD) or QuantiFERON TB Gold blood test.
N.Early 1 hour glucose challenge test (GCT), if patient has a prior history of gestational diabetes, family history of diabetes, obese (body mass index [BMI] 30 or higher), history of fetal macrosomia, or advanced maternal age (AMA).
O.Thyroid panel including TSH and free T4, if patient has a thyroid disorder or family history of a thyroid disorder.
P.Vaginal infection testing including chlamydia, gonorrhea, trichomonas, bacterial vaginosis, and candida.
Q.Pap smears performed on women 21 years and older:
1.Human papillomavirus (HPV) testing on all women 30 years and older.
R.Dating US before 14 weeks’ gestation.
Pharmaceutical Therapies
A.Prescribe a prenatal vitamin if the patient is not currently taking them:
1.Women less than 35 years old, prescribe a prenatal vitamin with the recommended 800 to 1,000 mcg daily of folic acid.
2.Women 35 years or older, prescribe a prenatal vitamin and increase their folic acid to 4,000 mcg daily.
B.Iron supplement:
1.Prophylaxis: Prenatal vitamins contain the recommended dose of iron.
2.Anemia: Increase elemental iron by 30 to 120 mg/d and instruct the patient to take the iron with orange juice to increase the absorption in the stomach.
Patient Education
A.Nutrition.
B.Recommended weight gain based on prepregnancy BMI.
C.Prenatal classes.
D.Substance abuse (alcohol, smoking, drugs).
E.Environmental exposures.
F.Domestic violence (history, type of injuries).
G.Over-the-counter (OTC) and herbal supplement medication use.
H.Activity (work, exercise).
I.Travel.
J.Personal hygiene.
K.Sexual activity.
L.Common discomforts/treatments in pregnancy.
M.Symptoms to report immediately.
Complications
A.Ectopic pregnancy.
B.Spontaneous abortion.
C.Missed abortion.
D.Blighted ovum.
E.Threatened abortion.
F.Urinary tract infection (UTI).
G.Pyelonephritis.
H.Anemia.
Consultations
A.Women, infants, and children (WIC).
B.History of asthma, need high-risk consultation.
C.History of cardiac abnormalities, need high-risk consultation.
Emergent Issues/Instructions
A.Nausea and vomiting are normal; however, if she is unable to eat or drink without vomiting she needs to be sent to the emergency room (ER) because of dehydration and abnormal electrolyte levels. Vitamin B6 and unisome are used as the drugs of choice to prevent nausea and ondansetron is used in more severe cases.
B.Abdominal pain and/or cramping, backache, pelvic pressure, or other pain need to be evaluated and sent to the ER.
C.Vaginal bleeding with or without pain needs to be evaluated and sent to the ER.