INTRODUCTION TO PRENATAL CARE - Ky CHFS

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Prenatal

Table of Contents

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CLINICAL PROTOCOLS

Prenatal Services Matrix 1

Guidelines for Prenatal Vitamins 3-4

Recommendations for Weight Gain during Pregnancy 4-5

CASE MANAGEMENT

Prenatal Lead Screening Guidelines 6

Hepatitis B 7

Hepatitis C 7

HIV Prevention of Perinatal Transmission 8

Triple Screen/ Multiple Marker Test 9

Cystic Fibrosis Screening ……………………………………………………………………… …. 9-10

Group B Streptococcus Screening …………………………………………………………… …..… 10

Herpes Simplex Virus (HSV) …………………………………………………………………… 10-11

Glucose Testing Guidelines and Management for Gestational Diabetes Mellitus 12-14

Counseling Protocols for Common Discomforts 15-18

PRENATAL SERVICE GUIDELINES

X= Required service; Services to be performed according to ACOG guidelines

| | | | | | |28 WEEKS |

|COMPONENT |INITIAL |INITIAL EXAM|RETURN |15–20 |20–24 | |

| |WORKUP | |VISITS |WEEKS |WEEKS | |

|Assess depression/postpartum depression |X |X |X | | | | |

|Complete physical exam | |X | | | | | |

|Blood type/Rh Factor |X | | | | | | |

|Rubella titer |X | | |

|Gonorrhea & Chlamydia & BV | |@ risk | |

|cultures | | | |

|Vitamin A |Age < 18 750 mcg. RAE |Age < 18 750 mcg. RAE | Age < 18 2800 mcg. RAE |

| |(3750 IU) |(3750 IU) |(14,000 IU) |

| |Age 19 – 50 770 mcg. RAE |Age 19 – 50 770 mcg. RAE |Age 19 – 50 3000 mcg. RAE |

| |(3850 IU) |(3850 IU) |(15,000 IU) |

|Vitamin D |5 mcg. (200 IU) |5 mcg. (200 IU) |100 mcg. (4000 IU) |

|Vitamin E |15 mg. |10 mg. | |

| |(10 IU) |(7 IU) |Age < 18 800 mg. (536 IU) |

| | | |Age 19 – 50 1000 mg. (670 IU) |

|Vitamin K |75 mg (age 18) |

| |1000 mg. (age 19–50) | |3,000 mg. (age 140-179 mg/dl), a 100 gram diagnostic Oral Glucose Tolerance Test (OGTT) is performed. (Do not proceed with 3 hour OGTT if 1-hour 50-gram load venous blood glucose is >180 mg/dl––refer to physician.)

• Schedule 3 hour OGTT within 7 days.

2. The Oral Glucose Tolerance Test (OGTT) is the diagnostic test for GDM.

• It is recommended that the OGTT be performed in the morning after an overnight fast of at least 8 hours but no greater than 14 hours. At least 3 days of unrestricted diet (150 gram carbohydrate per day) and unrestricted activity (unless otherwise contraindicated) need to precede the test.

• Women taking prescription medication should check with their health care provider for specific instructions.

• Women need to remain seated and not smoke during the test.

• A finger stick blood (capillary) sample along with a fasting venous (plasma) blood sample should be obtained prior to the administration of the commercially prepared glucose solution.

• If the fasting finger stick blood level is greater than 126 mg/dl, do not administer oral glucose without consulting the patient’s provider. The patient’s provider should determine whether or not to proceed with the 3 hour OGTT.

• If the fasting finger stick blood level is below 126 mg/dl proceed with the test. Venous blood samples are then collected at one, two, and three hour intervals.

Diagnosis

According to ACOG guidelines, diagnosis of GDM can be determined by the result of a 100 Gram, 3 hour oral glucose tolerance test.

Either the plasma or serum glucose level established by Carpenter and Coustan or the plasma level designated by the National Diabetes Data Group is appropriate to use.

A definitive diagnosis of GDM requires that two or more thresholds be met are exceeded.

|Table 1. Diagnostic Criteria for the 100 gram, 3 hour Oral Glucose Tolerance Test (OGTT) for GDM |

|Status |Carpenter and Coustan Conversion |National Diabetes Data Group Conversion |

| |Plasma or Serum Glucose Level |Plasma Level |

|Fasting |95 |105 |

|1 Hour |180 |190 |

|2 Hours |155 |165 |

|3 Hours |140 |145 |

| A positive diagnosis requires that two or more thresholds are met or exceeded |

|To make this test reliable, the patient must be fasting and administered a 100-gram commercially prepared solution. |

Management of Diagnosed GDM

• Refer to physician for medical management and fetal surveillance.

• Refer to dietitian (RD/LD) or for Medical Nutrition Therapy.

• Counsel about GDM and the need for postpartum follow-up.

• Counsel about self-monitoring of blood glucose (SMBG) and daily fetal kick counts. (starting at 26–32 weeks gestation)

Home Blood Glucose Monitoring and Follow-up:

|CONTROLLED |UNCONTROLLED |

|Fasting whole blood < 95 |Fasting whole blood >95 |

|Fasting plasma 105 |

| | |

|1 hr pp whole blood 140 |

|1 hr pp plasma 155 |

| | |

|2 hr pp whole blood 120 |

|2 hr pp plasma 130 |

| | |

|Continue current therapy |Refer to physician |

Note: Many blood glucose monitors now calibrate to plasma glucose. Values depend on the meter.

|GDM ASSESSMENT |APPROPRIATE SCREENING |RESULTS |MANAGEMENT |

|Abnormal BG at initial prenatal visit: |Refer immediately for subsequent |A fasting plasma glucose level |As directed by a qualified |

|Fasting BG > 126 mg/dl |testing – do not do further |> 126 mg/dl or a random |physician |

|Random (Casual) BG > 200 mg/dl |testing |(casual) plasma glucose > 200 | |

| | |mg/dl meets the threshold for | |

|Note: If a capillary specimen is performed, | |the diagnosis of diabetes, if | |

|the blood glucose meter must yield a plasma | |confirmed on a subsequent day | |

|equivalent value. | |unless unequivocal symptoms of | |

| | |hyperglycemia are present. | |

|All pregnant women should be screened for GDM|Plasma glucose following a 1-hour| 180 mg/dl | |

| |Perform 1-hour plasma glucose |180mg/dl |Refer to a physician |

|Postpartum screening for all women who had |Either a fasting plasma glucose, |Negative: ................
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