What are the American College of Obstetricians and Gynecologists (ACOG) guidelines for prenatal care?

ACOG Guidelines for Prenatal Care

The American College of Obstetricians and Gynecologists (ACOG) recommends a comprehensive prenatal care approach that includes regular visits, screening tests, and patient education, with the specific schedule and components tailored based on risk factors to optimize maternal and fetal outcomes. 1

Initial Prenatal Visit Components

• A preconception visit is ideal for all individuals planning pregnancy to optimize health, address modifiable risk factors, and provide education about healthy pregnancy 2
• HIV testing should be offered to all pregnant women at the first prenatal visit 1
• Screening for sexually transmitted infections should be performed at the first prenatal visit 1, 2
• A Papanicolaou (Pap) smear should be obtained if none has been documented during the preceding year 1
• Genetic screening should be offered to all pregnant women, consistent with recommendations for non-pregnant women 2
• Baseline laboratory tests should be performed to evaluate for potential complications, including complete blood count, blood type, antibody screen, and urinalysis 1
• Screening for substance use (alcohol, nicotine, prescription medications, and other drugs) should be conducted 2
• Screening for intimate partner violence should be performed 2

Recommended Visit Schedule and Monitoring

• While traditional prenatal care models have changed little since 1930, ACOG now recognizes that visit frequency can be adjusted based on individual risk factors 3
• For low-risk pregnancies, fewer visits may be appropriate, while high-risk pregnancies require more intensive monitoring 1
• Fasting and postprandial blood glucose monitoring are recommended for both gestational diabetes and pre-existing diabetes in pregnancy 1
• Regular blood pressure monitoring is essential, with increased frequency for those with chronic hypertension 1
• Serial fetal growth evaluations should be conducted every 4 weeks for patients with chronic hypertension 1

Special Considerations for High-Risk Pregnancies

• Women with preexisting diabetes who are planning pregnancy should ideally begin care in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, registered dietitian nutritionist, and diabetes care and education specialist 1
• For pregnant women with diabetes, glucose targets are: fasting plasma glucose <95 mg/dL and either 1-hour postprandial glucose <140 mg/dL or 2-hour postprandial glucose <120 mg/dL 1
• A1C target in pregnancy is <6% if achievable without significant hypoglycemia, but may be relaxed to <7% if necessary to prevent hypoglycemia 1
• All women undergoing cesarean delivery should receive sequential compression devices starting before surgery and continuing until fully ambulatory 1
• Women with previous history of deep venous thrombosis, pulmonary embolism, or inherited thrombophilia should receive both mechanical and pharmacologic prophylaxis for 6 weeks postoperatively 1

Fetal Monitoring and Interventions

• Suspected fetal macrosomia is not an indication for induction of labor, as induction does not improve maternal or fetal outcomes 1
• Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes 1
• For suspected fetal macrosomia with estimated weights over 5,000 g in non-diabetic women or over 4,500 g in women with diabetes, prophylactic cesarean delivery may be considered 1
• Fetal heart rate monitoring should be performed before and after surgery for viable fetuses when surgical intervention is required during pregnancy 1

Prevention of Complications

• Low-molecular-weight heparin is the preferred thromboprophylactic agent in pregnancy and the postpartum period 1
• Each institution should develop a patient safety bundle with an institutional protocol for venous thromboembolism prophylaxis among women who undergo cesarean delivery 1
• Preconception folic acid supplementation should be encouraged to reduce the risk of neural tube defects 2
• Patients with chronic hypertension should be monitored with increased frequency of prenatal visits (every 2-4 weeks) and prescribed automated home blood pressure devices for self-monitoring 1

Patient Education and Support

• Guidelines providing information about physical activity during pregnancy help pregnant women exercise during pregnancy with less anxiety 4
• Psychosocial support and education about pregnancy are important components of prenatal care that may be underemphasized in current practice 5
• ACOG now recognizes the need to address unmet social needs as part of prenatal care 3
• Incorporation of telemedicine and alternative care modalities is being recommended as part of a transformative approach to prenatal care 3

Common Pitfalls to Avoid

• Failure to screen for and address modifiable risk factors before conception 2
• Inadequate monitoring of high-risk conditions like diabetes and hypertension during pregnancy 1
• Unnecessary induction of labor for suspected fetal macrosomia 1
• Overlooking the importance of psychosocial support and education during prenatal visits 5
• Not providing appropriate thromboprophylaxis for women undergoing cesarean delivery 1