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 center developed by Georgetown University that provides learning and collaborative opportunities aimed at improving access to and quality of preconception and prenatal care

http://ncemch.org/

U.S. Department of Health and Human Services

A module from the Health Resources and Services Administration outlining quality measures for prenatal care and providing quality improvement tools for organizations looking to improve prenatal access

http://www.hrsa.gov/quality/toolbox/measures/prenatalfirsttrimester/part4.html

Walker PF, Barnett ED, eds. Immigrant Medicine. St. Louis, Mo.: Saunders Elsevier; 2007.

Textbook addressing the care of immigrant and refugee populations

Includes chapters on compassion, cultural competency, and health literacy

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 center developed by Georgetown University that provides learning and collaborative opportunities aimed at improving access to and quality of preconception and prenatal care

http://ncemch.org/

U.S. Department of Health and Human Services

A module from the Health Resources and Services Administration outlining quality measures for prenatal care and providing quality improvement tools for organizations looking to improve prenatal access

http://www.hrsa.gov/quality/toolbox/measures/prenatalfirsttrimester/part4.html

Walker PF, Barnett ED, eds. Immigrant Medicine. St. Louis, Mo.: Saunders Elsevier; 2007.

Textbook addressing the care of immigrant and refugee populations

Includes chapters on compassion, cultural competency, and health literacy

One common challenge associated with late-to-care pregnancies is when the patient is uncertain of the timing of her last menstrual period and she has not undergone previous ultrasonography. In these cases, the initial ultrasonography may not occur until late in the third trimester. This delay is associated with increased rates of postterm inductions and delayed diagnosis of multifetal gestation, resulting in additional maternal and fetal risks.12

Other challenges may include inadequate prenatal genetic screening, late diagnosis of gestational diabetes mellitus, inadequate treatment of chronic medical conditions, and potential strain on the patient-physician relationship. Table 3 provides a general guide to the overall assessment of patients and the provision of late prenatal care.13,14

View/Print Table

Table 3.

Guide to the Assessment and Treatment of Patients Presenting Late to Prenatal Care

Components of careComments

Initial assessment

Address the relevant issues involving safety, psychosocial health, substance abuse, insurance status and access to care, homelessness, immigration, and perspectives on prenatal care

History

History of current pregnancy including LMP; previous prenatal care; drug or medication use during pregnancy; complete medical, obstetric, and surgical history; social history; vaccination history; and history of herpes or chickenpox during this pregnancy

Physical examination

Vital signs, fundal height, fetal heart rate, and position; assess for cesarean delivery scar or bacillus Calmette-Guérin vaccination scar to guide approach

Laboratory tests

Routine first-trimester tests, including complete blood count to screen for anemia, urine culture, and sexually transmitted infection tests for hepatitis B virus, human immunodeficiency virus, and syphilis infections, as well as gonorrhea, chlamydia, and hepatitis C virus infection if patient is at high risk*

Gestational diabetes mellitus testing if > 24 weeks' gestation

Group B streptococcus if patient may be > 35 weeks' gestation

QuantiFERON-TB Gold test if bacillus Calmette-Guérin scar is present or tuberculin skin tests if no scar

Routine screening for toxoplasmosis, cytomegalovirus, or parvovirus is not recommended

Ultrasonography

Assess fetal anatomy, fetal biometry, and estimated due date, especially if the patient's LMP is unclear or if she is at increased risk of fetal anomalies (e.g., due to advanced maternal age or exposure to teratogenic medication)

Vaccinations

Tdap if > 27 weeks' gestation

Inactivated influenza if during influenza season

Medical record procurement

Even in the case of international patients, records (including early pregnancy–dating ultrasonography) can often be sent electronically

Attempt to procure surgical reports if the patient had a previous cesarean delivery and is considering a trial of labor†

Estimated due date

If patient is certain of her LMP and has a history of regular menstrual cycles, LMP can be used to calculate estimated due date

If LMP is uncertain or patient has a history of irregular periods, use dating from the earliest available ultrasonography

If estimated due date by ultrasonography differs from that of LMP by > 8% (in days), use estimated due date from ultrasonography13

Management considerations

Prescribe iron for anemia; treat infection or gestational diabetes; plan for postterm pregnancy (consider initiating biweekly fetal nonstress tests at the earliest time that the patient could reach 41 weeks' gestation based on the earliest ultrasonography and using a margin of error of +/– 8%)

Risk stratification

Determine if the patient has any additional high-risk issues (e.g., preeclampsia, multiparity, history of previous cesarean delivery or gestational diabetes) and manage appropriately

Consider referral if necessary


LMP = last menstrual period; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine.

*—Risk factors for gonorrhea and chlamydia: age younger than 25 years, unmarried, black race, history of sexually transmitted infections, multiple sex partners, cervical ectropion, inconsistent use of barrier contraception, and living in a community with a high infection rate. Risk factors for hepatitis C virus infection: incarceration, intravenous drug use, exposure to blood products, human immunodeficiency virus infection, elevated aspartate transaminase level, multiple sex partners, and tattoos.

†—Trial of labor is not contraindicated for women with one prior cesarean delivery with an unknown uterine scar unless there is a high clinical suspicion of a previous classical uterine incision, such as cesarean delivery before 30 weeks' gestation.14

Information from references 13 and 14.

Table 3.

Guide to the Assessment and Treatment of Patients Presenting Late to Prenatal Care

Components of careComments

Initial assessment

Address the relevant issues involving safety, psychosocial health, substance abuse, insurance status and access to care, homelessness, immigration, and perspectives on prenatal care

History

History of current pregnancy including LMP; previous prenatal care; drug or medication use during pregnancy; complete medical, obstetric, and surgical history; social history; vaccination history; and history of herpes or chickenpox during this pregnancy

Physical examination

Vital signs, fundal height, fetal heart rate, and position; assess for cesarean delivery scar or bacillus Calmette-Guérin vaccination scar to guide approach

Laboratory tests

Routine first-trimester tests, including complete blood count to screen for anemia, urine culture, and sexually transmitted infection tests for hepatitis B virus, human immunodeficiency virus, and syphilis infections, as well as gonorrhea, chlamydia, and hepatitis C virus infection if patient is at high risk*

Gestational diabetes mellitus testing if > 24 weeks' gestation

Group B streptococcus if patient may be > 35 weeks' gestation

QuantiFERON-TB Gold test if bacillus Calmette-Guérin scar is present or tuberculin skin tests if no scar

Routine screening for toxoplasmosis, cytomegalovirus, or parvovirus is not recommended

Ultrasonography

Assess fetal anatomy, fetal biometry, and estimated due date, especially if the patient's LMP is unclear or if she is at increased risk of fetal anomalies (e.g., due to advanced maternal age or exposure to teratogenic medication)

Vaccinations

Tdap if > 27 weeks' gestation

Inactivated influenza if during influenza season

Medical record procurement

Even in the case of international patients, records (including early pregnancy–dating ultrasonography) can often be sent electronically

Attempt to procure surgical reports if the patient had a previous cesarean delivery and is considering a trial of labor†

Estimated due date

If patient is certain of her LMP and has a history of regular menstrual cycles, LMP can be used to calculate estimated due date

If LMP is uncertain or patient has a history of irregular periods, use dating from the earliest available ultrasonography

If estimated due date by ultrasonography differs from that of LMP by > 8% (in days), use estimated due date from ultrasonography13

Management considerations

Prescribe iron for anemia; treat infection or gestational diabetes; plan for postterm pregnancy (consider initiating biweekly fetal nonstress tests at the earliest time that the patient could reach 41 weeks' gestation based on the earliest ultrasonography and using a margin of error of +/– 8%)

Risk stratification

Determine if the patient has any additional high-risk issues (e.g., preeclampsia, multiparity, history of previous cesarean delivery or gestational diabetes) and manage appropriately

Consider referral if necessary


LMP = last menstrual period; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine.

*—Risk factors for gonorrhea and chlamydia: age younger than 25 years, unmarried, black race, history of sexually transmitted infections, multiple sex partners, cervical ectropion, inconsistent use of barrier contraception, and living in a community with a high infection rate. Risk factors for hepatitis C virus infection: incarceration, intravenous drug use, exposure to blood products, human immunodeficiency virus infection, elevated aspartate transaminase level, multiple sex partners, and tattoos.

†—Trial of labor is not contraindicated for women with one prior cesarean delivery with an unknown uterine scar unless there is a high clinical suspicion of a previous classical uterine incision, such as cesarean delivery before 30 weeks' gestation.14

Information from references 13 and 14.

Returning to the case scenario, the physician should order routine prenatal laboratory tests, including blood type, rubella immunization status, glucose challenge test, and testing for sexually transmitted infections. A quantiFERON-TB Gold test should be performed, and a positive result should trigger a referral for chest radiography. A fetal scan should be performed, and vaccines for inactivated influenza and for tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) should be administered. The patient should be encouraged to have a family member in the Dominican Republic attempt to procure her initial ultrasonography and prior operative report from her cesarean delivery. Follow-up appointments should be scheduled with the social worker as well as her new primary care physician.

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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