SOAP. – Prenatal Care: Second Trimester Overview

Include components of the first trimester evaluation (see previous text) at the patient’s initial visit.

Physical Examination

A.General assessment:

1.Vital signs.

2.Weight.

3.Blood pressure (BP).

4.Fetal heart tones (120–160 bpm).

5.Fetal movement, usually first felt between 18 and 22 weeks.

6.Fundal height.

B.Abdomen:

1.Measure the fundal height.

C.Skin:

1.Striae distensae.

2.Varicose veins.

D.Extremities:

1.Edema.

Common Diagnostic Tests

A.Test of cure for urinary tract infections (UTIs) and sexually transmitted infections (STIs) previously treated.

B.Genetic testing offered to all women: Maternal serum multiple marker screening (quad screen) between 15 weeks, 6 days and 21 weeks, 6 days. Genetic testing offered to women who are advanced maternal age (AMA), history of genetic abnormalities, history of prior fetal abnormalities, and positive quad screen: Noninvasive prenatal testing (NIPT). Patient consent is needed:

1.Amniocentesis/Chorionic villus sampling (CVS), if applicable.

C.Fetal anatomy ultrasound (US) at 20 weeks’ gestation.

D.Gestational diabetes screening with 1 hour GCT between 24 and 28 weeks. If the 1 hour 50 g GCT is above or equal to 135, the patient needs to complete the 3 hour 100 g glucose tolerance test (GTT). Gestational diabetes is diagnosed when two or more out of four values from the 3-hour 100 g GTT are equal or higher than the cutoffs.

Pharmaceutical Therapies

A.Influenza vaccine (seasonal).

B.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.Physiological changes during pregnancy.

B.Fetal development.

C.Father’s role during pregnancy.

D.Genetic testing in pregnancy.

E.Review symptoms to report immediately.

Complications

A.UTIs.

B.Pyelonephritis.

C.Preeclampsia and eclampsia.

D.Gestational diabetes.

E.Anemia.

F.Fetal abnormalities.

G.Abnormal genetic screening results.

H.STIs.

Consultations

A.Genetic consultation is needed with abnormal genetic testing, AMA, and abnormal US findings.

B.High-risk consultation is needed with gestational diabetes, thyroid disorder, asthma exacerbation in pregnancy, severe anemia unresponsive to treatment, HIV-positive, acute tuberculosis infection, congenital syphilis, positive antibody, fetal abnormalities, and maternal cardiac complications.

Emergent Issues/Instructions

A.Abdominal pain, contractions, backache, pelvic pressure, or other pain needs to be evaluated and sent to the ER.

B.Vaginal bleeding with or without pain needs to be evaluated and sent to the ER.

C.Fever greater than 100.4.

D.Evaluate fetal movement, noting when movement was first felt (quickening). If she reports decreased fetal movement send to the ER to have biophysical profile (BPP) and nonstress test (NST) to evaluate fetal well-being.

E.Headaches with or without blurry vision need to be addressed. BP should be monitored and if she has elevated BP with or without headaches and blurry vision she needs to be sent to the ER.

F.Leaking of clear fluid from the vagina needs to be assessed and if she has unexplained fluid from the vagina she needs to go to the ER.