What is the recommended approach for a prenatal consult?

Comprehensive Approach to Prenatal Consultation

The recommended approach for a prenatal consultation should include a structured assessment of reproductive life planning, medical and family history, risk factors, genetic screening, lifestyle modifications, and psychosocial factors to optimize pregnancy outcomes and reduce maternal and fetal morbidity and mortality.

Initial Assessment

• Begin by asking "Would you like to become pregnant in the next year?" to establish pregnancy intentions and guide appropriate counseling 1, 2
• Review reproductive history, including previous adverse pregnancy outcomes (infant death, fetal loss, birth defects, low birth weight, preterm birth) 1
• Assess medical history for conditions that could affect pregnancy (rheumatic heart disease, thromboembolism, autoimmune diseases, hypertension, diabetes) 1
• Evaluate medication use, identifying FDA pregnancy category X and D medications that may require adjustment before conception 1

Risk Assessment

• Screen for age-related risks (maternal age ≥35 years increases risk of chromosomal anomalies) 1, 3
• Identify consanguinity, which requires review of pedigree and assessment of degree of relatedness 1
• Evaluate family history of genetic disorders and offer appropriate carrier screening 1, 3
• Assess for previous pregnancy complications that may recur in subsequent pregnancies 1
• Screen for substance use (tobacco, alcohol, drugs) using validated tools like CAGE or T-ACE questionnaires 1

Physical Examination and Laboratory Testing

• Conduct focused physical examination with emphasis on periodontal, thyroid, heart, breast, and pelvic examinations 1
• Order laboratory testing including complete blood count, urinalysis, blood type and screen 1
• Screen for infections as indicated (rubella, syphilis, hepatitis B, HIV, gonorrhea, chlamydia) 1
• Consider measuring thyroid-stimulating hormone levels, particularly in women with symptoms or history of thyroid disease 1

Nutritional and Supplement Recommendations

• Prescribe folic acid supplementation (400-800 mcg daily) starting at least 3 months before conception to reduce neural tube defect risk by nearly 75% 3, 4, 5
• Consider higher dose folic acid (4-5 mg daily) for women with specific risk factors (epilepsy, insulin-dependent diabetes, obesity with BMI >35) 3, 4
• Promote healthy prepregnancy weight (ideal BMI 19.8-26.0 kg/m²) through exercise and nutrition 1
• Encourage consumption of two servings of fruit and three servings of vegetables daily ("five-a-day") 1

Immunization and Infection Prevention

• Update immunizations as needed: hepatitis B, rubella, varicella (if no evidence of immunity), Tdap, HPV, and influenza 1
• Counsel on preventing TORCH infections (Toxoplasmosis, Other viruses, Rubella, Cytomegalovirus, Herpes simplex) 1
• Screen for periodontal, urogenital, and sexually transmitted infections as indicated 1

Lifestyle Modifications

• Promote healthy behaviors: nutrition, exercise, safe sex, effective contraceptive use if not planning immediate pregnancy 1
• Discourage risky behaviors: douching, not wearing seatbelts, smoking, alcohol and substance abuse 1
• Provide smoking cessation interventions using the five A's approach (Ask, Advise, Assess, Assist, Arrange) 1
• Advise complete abstinence from alcohol when trying to conceive 3

Environmental and Occupational Assessment

• Counsel about possible toxins and exposure to teratogenic agents at home, in the neighborhood, and workplace 1
• Assess for exposure to heavy metals, solvents, pesticides, endocrine disruptors, and allergens 1
• Review Material Safety Data Sheets and consult teratology information specialists as needed 1

Psychosocial Evaluation

• Screen for depression, anxiety, domestic violence, and major psychosocial stressors 1
• Evaluate for intimate partner violence and provide appropriate referrals if needed 3
• Assess for social determinants of health that may impact pregnancy outcomes 5

Chronic Disease Management

• Optimize control of diabetes through intensive management before pregnancy 3, 6
• Ensure hypertension is well-controlled using pregnancy-safe medications 3, 6
• Manage thyroid disease with appropriate medication adjustments 3, 6
• Review and modify medications for epilepsy, thromboembolism, depression, and anxiety as necessary 6

Special Considerations

• For women with previous fetal surgery, counsel about increased risks in subsequent pregnancies, including uterine rupture (9.6%) 1
• Discuss mental health support for pregnancies complicated by fetal anomalies, as these women have higher rates of anxiety and depression 1
• For women with heart disease, provide counseling about mortality risk based on modified WHO classification 1

Follow-up Planning

• Schedule appropriate referrals to maternal-fetal medicine specialists and other subspecialists for women with high-risk conditions 1
• Develop a plan for ongoing risk assessment throughout pregnancy, as this should be a continuous process 1
• Arrange for genetic consultation when indicated by age, ethnic background, or family history 1, 3

Common Pitfalls to Avoid

• Failing to screen for and address modifiable risk factors before conception 1, 7
• Overlooking the need to adjust medications that may be teratogenic 1
• Not providing adequate time for patients to process information, ask questions, and consult with their support system 1
• Neglecting to validate and support the patient's view and tolerance of risk 1