What are the initial steps and orders for a patient presenting for her first prenatal check with a confirmed pregnancy via ultrasound and 2 positive pregnancy tests (PTs)?

Initial Prenatal Visit Orders and Management

For a patient with confirmed intrauterine pregnancy via ultrasound and two positive pregnancy tests, order comprehensive laboratory testing, initiate prenatal vitamins with folic acid, provide pregnancy education, and establish ongoing prenatal care with appropriate follow-up scheduling.

Immediate Laboratory Orders

Order the following baseline laboratory tests at the first prenatal visit:

• Complete blood count (CBC) to assess for anemia and establish baseline hemoglobin 1
• Blood type and Rh status to identify need for Rh immunoglobulin prophylaxis 1
• Antibody screen to detect red cell alloantibodies 1
• Rubella immunity status (IgG antibody) 1
• Hepatitis B surface antigen (HBsAg) 1
• HIV screening (with appropriate counseling and consent per local requirements) 1
• Syphilis screening (RPR or VDRL) 1
• Urinalysis and urine culture to screen for asymptomatic bacteriuria 1
• Cervical cancer screening (Pap smear) if due per guidelines 1

Prenatal Vitamin Supplementation

Prescribe prenatal vitamins containing folic acid immediately:

• Folic acid supplementation is consistently covered in first prenatal visits and closely adheres to ACOG guidelines 1
• Standard prenatal vitamins should contain at least 400-800 mcg of folic acid 1

Immunizations

Administer influenza vaccine if during flu season:

• Flu vaccination is one of the topics that closely adheres to ACOG guidelines and is covered in most first prenatal visits 1

Ultrasound Considerations

Since ultrasound has already confirmed intrauterine pregnancy, document the following:

• Gestational age and estimated due date based on ultrasound measurements 2
• Number of fetuses (to detect multiple pregnancy early) 2
• Viability (presence of cardiac activity if gestational age appropriate) 2

Consider detailed first-trimester ultrasound between 11-13.6 weeks if not already performed:

• Detailed first-trimester ultrasound identifies 5.4% additional fetuses requiring follow-up beyond what standard screening detects 3
• First-trimester screening can detect lethal anomalies with 91.3% sensitivity 4
• Nuchal translucency measurement should be obtained between 11-14 weeks for aneuploidy screening 5

Prenatal Screening Options

Discuss and offer aneuploidy screening:

• First-trimester combined screening (11-14 weeks) includes nuchal translucency, PAPP-A, and free beta-hCG or intact hCG, achieving 82-86% detection rate for Down syndrome 5
• Free beta-hCG performs better than intact hCG at 11 weeks (2-3% higher detection) 5
• Noninvasive prenatal testing (NIPT) should be offered to all patients per current ACOG recommendations 3

Psychosocial Screening

Screen for psychosocial risk factors:

• Screening for identification of psychosocial risk is discussed less often than laboratory testing but remains important 1
• Assess for substance use disorders; verify urine sample belongs to pregnant woman when screening 5
• Screen for intimate partner violence, depression, and social support 1

Patient Education Topics

Provide education on the following (noting these are often inadequately covered):

• Normal pregnancy symptoms and warning signs requiring immediate evaluation 1
• Nutrition and weight gain recommendations 1
• Activity and exercise guidelines 1
• Medications and substances to avoid during pregnancy 1
• Prenatal visit schedule and what to expect 1

Follow-Up Planning

Establish prenatal care schedule:

• Standard prenatal visit frequency: every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, then weekly until delivery 1
• Schedule next visit for 4 weeks or sooner if first-trimester screening is planned 1

Critical Pitfalls to Avoid

Do not defer ultrasound evaluation even with confirmed pregnancy:

• Early ultrasound improves detection of multiple pregnancies and provides accurate gestational dating, reducing unnecessary inductions for post-maturity 2
• Two-stage screening (first and second trimester) detects 83.8% of structural anomalies versus 50.5% with single second-trimester scan alone 4

Ensure comprehensive laboratory screening is completed:

• Many components of ACOG guidelines are not closely followed in practice, particularly comprehensive laboratory testing and patient education 1

Document all findings carefully:

• Establish accurate gestational age early, as this affects interpretation of all subsequent testing and management decisions 2