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Any medical visit with a female patient of childbearing age is an opportunity to offer basic counseling on preconception health, an essential conversation given that nearly 50% of pregnancies are unplanned.
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KEY FACT
Preconception medical care and prenatal care share the same goal to minimize risk of harm to mother or baby (control medical conditions and prevent illness, eg, with vaccination).
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Diagnosis of Pregnancy
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Common symptoms of pregnancy include breast tenderness, fatigue, and nausea or vomiting. Signs on physical exam in the early first trimester include Chadwick sign (blue cervix) or Goodell sign (cervical softening), and palpable uterine enlargement.
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Diagnose with urine qualitative hCG assay (98% sensitivity 7 days after implantation), serum quantitative β-hCG assay (sensitivity 4-5 days after implantation), or pelvic ultrasound (a gestational sac is usually visible 5-6 weeks after the last menstrual period [LMP]).
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The estimated date of delivery can be established by the following in the first trimester:
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LMP + 40 weeks, adjusting for cycle length if different from 28 days.
Ultrasound measurement of crown-rump length in millimeters, most reliable method.
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KEY FACT
Do not assume that every patient with a ⊕ pregnancy test desires the pregnancy. Counsel patients on options appropriately. If a provider is unable or unwilling to provide medication or aspiration abortion when a patient chooses the option, he or she is obligated to refer for a safe and legal termination.
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For ultrasonography dating in the second trimester, also consider the following:
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KEY FACT
Gestational age assessment by ultrasound measurement:
<14 weeks: Accuracy of ± 5-7 days
14-22 weeks: Accuracy of ± 7-10 days
22-28 weeks: Accuracy of ± 10-14 days
>28 weeks: Accuracy of ± 21-30 days
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Prenatal Care in the First Trimester
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The goals of the initial prenatal visit are four-fold:
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Identify patients with undesired pregnancies and refer for adoption counseling/abortion if applicable.
Identify any medical or psychosocial problems that merit immediate attention.
Establish the gestational age of the pregnancy.
Begin patient education.
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Prenatal Risk Assessment and Lab Workup
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Physical exam: A full exam, including a thyroid, breast, and pelvic exam, along with BP screening, performed within 1 to 2 weeks of diagnosis. After 9 to 12 weeks of gestation, fetal heart tones auscultated at each visit with a Doppler ultrasound.
Medical history: Metabolic and autoimmune diseases, cardiac disease; reproductive history, including gynecologic or pregnancy complications and DES exposure; medication use (prescription drugs, OTC medications, and herbal supplements, teratogenic medications).
Family history: CF, thalassemia, sickle cell anemia, birth defects, endocrine disorders, thromboembolic disease, and multiple gestation.
Psychosocial history: Domestic violence, financial stability, emotional support, and barriers to care; substance use (EtOH, ...