Prenatal Counseling
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Overview of prenatal care: Patients should be counseled regarding the frequency of prenatal visits, routine pregnancy monitoring, how to reach after-hours care, and other resources that may be available (eg, childbirth classes).
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Nutrition: Patients should follow a healthy, balanced diet, aiming for BMI-adjusted weight gain: 25 to 35 pounds for BMI 20 to 25; 10 to 15 pounds for a BMI >26; 35 to 45 pounds for a BMI <19.8. They should also be counseled to avoid uncooked food, unpasteurized dairy products, mercury-containing fish, and excess vitamin A. A daily prenatal vitamin with at least 400 μg of folic acid can help prevent neural tube defects.
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Drug/alcohol cessation: Alcohol use is associated with growth restriction, small-for-gestational-age babies, fetal alcohol syndrome, and other effects of fetal exposure to alcohol. Some illicit drugs are associated with preterm birth, poor growth, and neonatal abstinence syndrome. Substance use treatment can be highly effective and should be initiated promptly. Opioid use disorders should be treated with Methadone or Buprenorphine.
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Tobacco cessation: Smoking during pregnancy is associated with low birth weight, prematurity, and an ↑ risk of miscarriage and thromboembolic events. Nicotine patches or gum may be used to aid in tobacco cessation; the use of bupropion is not well studied in pregnancy.
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Safety: Screen all patients for domestic violence. Patients should avoid trauma (no contact sports; use seat belts), environmental toxins (organic solvents, lead, radiation), extremes of temperature (no hot tubs), and prolonged immobility. Toxoplasmosis and Listeria precautions should also be discussed (eg, avoid raw meat/fish, unpasteurized dairy products, and cat litter), as should safe sex practices.
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Genetic counseling: All women should be offered nuchal translucency testing for Down syndrome and quadruple screening with serum AFP, hCG, estriol, and inhibin A. If these tests suggest a high risk of genetic disorders, additional testing and services should be offered, including genetic counseling, cell free fetal DNA testing, amniocentesis, chorionic villus sampling, and a detailed anatomic survey by ultrasound.
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Pregnant women should not receive live attenuated vaccines for MMR and varicella; recommend immunization postpartum. Gamma-globulin for protection from rubella is not recommended, given that herd immunity should protect most patients in the United States from contracting the disease.