Curbside Consultation

Late Presentation to Prenatal Care

 


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Am Fam Physician. 2015 Sep 1;92(5):391-397.

Case Scenario

A 26-year-old gravida 2, para 1 Dominican woman presents to my clinic for a prenatal visit. She is unsure of her due date and states that her last menstrual period was about seven or eight months ago. She received some prenatal care in the Dominican Republic, although she does not have any records from her physician. She reports that she has had an uncomplicated pregnancy so far, and that an earlier ultrasonography indicated that she is going to have a boy. Her medical history is unremarkable aside from a full-term cesarean delivery performed in the Dominican Republic four years ago because of “a cord around the baby's neck.” She is taking a daily prenatal vitamin. On examination, her vital signs are unremarkable, her fundal height measures 31 cm, the fetal heart rate is 140 beats per minute, and the fetus is cephalic by Leopold maneuvers. She has a 16-cm transverse scar along her waistline and a circular 3-cm scar on her right shoulder over the deltoid. She completed an application for health insurance with the clinic's social worker just before her visit with me. How can I best minimize risks and optimize health for this patient presenting late to prenatal care?

Commentary

Pregnancy carries concrete and immediate risks that need to be addressed and managed in a timely fashion. Patients who initiate prenatal care late in pregnancy tend to present with a challenging variety of concerns, encompassing the full range of their medical, psychosocial, and economic well-being.

Family physicians promote preconception and early prenatal care, and strive to identify groups at risk of late presentation to prenatal care. Table 1 lists factors associated with late presentation.18 Characterizing late-to-care patients through a sociocultural lens alone may be overly simplistic, because patients with poor reproductive health knowledge, delayed recognition of pregnancy, or a different perception of the value of prenatal care may not fit into conventional risk categories.8

View/Print Table

Table 1.

Risk Factors for Late Presentation to Prenatal Care

Adolescence

Delayed recognition of pregnancy

Greater multiparity

Immigrant status

Lack of preexisting obstetric care provider

Low level of education

Lower socioeconomic status

Membership in a specific group of marginalized persons*

Minority or nonwhite ethnic group

Nontraditional perception of the value of prenatal care

Poor reproductive health knowledge

Primiparous with complex medical history

Undocumented immigrant status

Unemployment

Uninsured


*—Patients who are refugees, homeless, or asylum seeking, or patients with a history of substance abuse or intimate partner violence.

Information from references 1 through 8.

Table 1.

Risk Factors for Late Presentation to Prenatal Care

Adolescence

Delayed recognition of pregnancy

Greater multiparity

Immigrant status

Lack of preexisting obstetric care provider

Low level of education

Lower socioeconomic status

Membership in a specific group of marginalized persons*

Minority or nonwhite ethnic group

Nontraditional perception of the value of prenatal care

Poor reproductive health knowledge

Primiparous with complex medical history

Undocumented immigrant status

Unemployment

Uninsured


*—Patients who are refugees, homeless, or asylum seeking, or patients with a history of substance abuse or intimate partner violence.

Information from references 1 through 8.

The role of prenatal care as an effective method of preventing pregnancy-related adverse outcomes is supported by a robust body of literature. Additionally, the value of initiating prenatal care during early pregnancy is not disputed. Nevertheless, evidence equating late presentation to prenatal care with adverse pregnancy outcomes is limited.

Reports on maternal mortality in the general population have identified delayed presentation to prenatal care as a significant risk factor for maternal death in all women, but especially in minorities.9 Late presentation to prenatal care has also been associated with increased rates of preterm delivery, low birth weight, and congenital malformations, compared with initiation of care in the first trimester.10,11

In the teenaged population, initiating prenatal care in the third trimester is associated with a twofold increase in the delivery of a low-birth-weight infant. Late presentation to care in teenaged patients is also associated with a lower body mass index, decreased weight gain in pregnancy, and a higher incidence of anemia.1

No published guidelines exist on treating patients who are late to prenatal care. However, reviews of evidence-based prenatal care, including third trimester–specific recommendations, can be used as a guide in the approach to care. Table 2 includes a list of resources on providing prenatal care.

View/Print Table

Table 2.

Resources on Providing Prenatal Care

ResourceDescription

AFP By Topic

Online collection of evidence-based articles on prenatal care

http://www.aafp.org/afp/prenatal

National Center for Education in Maternal and Child Health

Resource

The authors thank Michelle Olivieri, BBA, and Wendy Barr, MD, MPH, MSCE, for their assistance in the preparation of the manuscript.

Address correspondence to Andrew Smith, MD, at ASmith@glfhc.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Haeri S, Guichard I, Saddlemire S. Maternal characteristics and outcomes associated with late enrollment for care in teenage pregnancies. South Med J. 2009;102(3):265–268....

2. Rowe RE, Garcia J. Social class, ethnicity and attendance for antenatal care in the United Kingdom: a systematic review. J Public Health Med. 2003;25(2):113–119.

3. Beeckman K, Louckx F, Putman K. Predisposing, enabling and pregnancy-related determinants of late initiation of prenatal care. Matern Child Health J. 2011;15(7):1067–1075.

4. Munro K, Jarvis C, Munoz M, D'Souza V, Graves L. Undocumented pregnant women: what does the literature tell us? J Immigr Minor Health. 2013;15(2):281–291.

5. Kupek E, Petrou S, Vause S, Maresh M. Clinical, provider and sociodemographic predictors of late initiation of antenatal care in England and Wales. BJOG. 2002;109(3):265–273.

6. Downe S, Finlayson K, Walsh D, Lavender T. ‘Weighing up and balancing out’: a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries. BJOG. 2009;116(4):518–529.

7. Cha S, Masho SW. Intimate partner violence and utilization of prenatal care in the United States. J Interpers Violence. 2014;29(5):911–927.

8. Haddrill R, Jones GL, Mitchell CA, Anumba DO. Understanding delayed access to antenatal care: a qualitative interview study. BMC Pregnancy Childbirth. 2014;14:207.

9. Cantwell R, Clutton-Brock T, Cooper G, et al. Saving mothers' lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The eighth report of the confidential enquiries into maternal deaths in the United Kingdom [published correction appears in BJOG. 2015; 122(5):e1]. BJOG. 2011;118(suppl 1):1–203.

10. Castelló A, Río I, Martinez E, et al. Differences in preterm and low birth weight deliveries between Spanish and immigrant women: influence of the prenatal care received. Ann Epidemiol. 2012;22(3):175–182.

11. Carmichael SL, Shaw GM, Nelson V. Timing of prenatal care initiation and risk of congenital malformations. Teratology. 2002;66(6):326–330.

12. Whitworth M, Bricker L, Neilson JP, Dowswell T. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev. 2010;(4):CD007058.

13. Hadlock FP, Shah YP, Kanon DJ, Lindsey JV. Fetal crown-rump length: reevaluation of relation to menstrual age (5–18 weeks) with high-resolution real-time US. Radiology. 1992;182(2):501–505.

14. American College of Obstetricians and Gynecologists. ACOG practice bulletin no. 115: vaginal birth after previous cesarean delivery. Obstet Gynecol. 2010;116(2 pt 1):450–463.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, Associate Deputy Editor.

A collection of Curbside Consultation published in AFP is available at http://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.



 

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