Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2

Guidelines for the First Prenatal Visit

A number of significant environmental, psychosocial, and treatment considerations should be taken into account at the time of the woman's first prenatal visit. These considerations can affect the accurate assessment and successful engagement of the woman in ongoing prenatal care. They are as follows:

• Services should be provided in a supportive, culturally sensitive, and nonjudgmental environment by all health care personnel, from the receptionist to the physician.
• An assessment should be made of the woman's literacy and reading level. This assessment should include the woman who is functionally illiterate or has low literacy in her native tongue as well as in English. Literacy- and reading-level information will affect patient education efforts and the ability to obtain informed consent.
• The woman may enter prenatal care in different stages of pregnancy and from a variety of settings, including hospital emergency rooms, community health centers, family planning clinics, abortion clinics, or social service offices. It is essential to be able to offer assessment, triage, case coordination, and referral services from any or all of these settings.
• Case management services that coordinate the care of the pregnant, substance-using woman and her family are critical. Ideally, case conferences and referral to appropriate services should be managed by one health care professional who oversees the multidisciplinary team. An outreach worker who visits the woman in her home should be part of this team. The most difficult issue to resolve, given the financial and staffing constraints experienced by most health care and service providers, is the identification and designation of a case manager.
• Counseling about and obtaining of written informed consent for medical procedures and treatment are important. It is equally important to explain confidentiality, privacy, and other patient rights, as well as legal risks that may be posed by policies of the individual program.

The first prenatal visit should establish the components of the continuum of care that will extend through the woman's pregnancy and beyond. The visit should include the following components.

1 Obtain a detailed health history. This history should cover legal and illegal drug use and last date of use; drugs used at the time of the first visit; medical history; current medications; psychosocial history, including emotional problems, mental illness, and housing and current living arrangements, with a special focus on the presence or lack of support systems; complete reproductive history, including current and past pregnancies, previous preterm deliveries, history of Caesarean sections, birth weight, number of therapeutic abortions, menstrual history, and methods of family planning; and sexual history, including previous sexually transmitted diseases.

2 Conduct a comprehensive physical examination. This examination should be performed during the initial prenatal evaluation. It should include an evaluation of nutritional status, height, weight, and blood pressure, as well as an examination of the head, neck, breasts, heart, lungs, abdomen, pelvis, rectum, and extremities. Special attention should be given to those organ systems impacted by alcohol and other drug use, such as the liver in alcoholics and the skin in injection drug users. During the pelvic examination, attention should be given to the size of the uterus in relation to the presumed duration of the pregnancy.

3 Obtain a family psychosocial, medical, and substance-using history. This history should cover alcohol and other drug use by all family members, diabetes, tuberculosis, cancer, heart disease (hypertension), congenital malformations, multiple births, and bleeding disorders. If any part of the history will have a significant impact on the course or outcome of the pregnancy, appropriate followup should be initiated. A visit to the woman's living environment should be an option.

4 Obtain a health, psychosocial, and substance-using history for the infant's father. This history should cover legal and illegal drug use, alcohol and other drugs currently being used, medical history, and mental illness.

5 Complete a prenatal panel that includes

• Initial blood workup for all women that includes, but is not limited to
  • Blood group, Rh factor determination, and antibody screen
  • Rubella immune status and antibody titer measurement, unless previously documented
  • Serological tests for syphilis
  • Hepatitis B surface antigen screen
  • Complete blood count, including indices and platelets
  • Baseline liver function test
  • Baseline renal function test
• Other initial laboratory tests for all women that include, but are not limited to:
  • Cervical cytology (pap smear), unless the provider has results of a test performed within the last 3 months
  • Cervical culture for gonorrhea (optional culture for rectal and pharyngeal)
  • Chlamydia screen
• Hemoglobin electrophoresis as indicated
• Urine drug and/or blood screening (the selection of drugs for screening will vary by community and should be based on current local prevalence data).
• Human immunodeficiency virus (HIV) education and counseling. Offer antibody testing, with pre- and posttest counseling. Always obtain written informed consent that is consistent with the laws and regulations of the locale.
• Purified protein derivative of tuberculin (PPD) with antigen panel. If previously PPD-positive, a chest X-ray is recommended.
• Baseline sonogram. Level I scanning should be performed at a minimum to assess gestational age. Level II is recommended, especially when the gestational age is more than 18 weeks.

6 Obtain optional tests. The benefit-to-cost ratio of these tests at the initial prenatal visit may vary depending on the population:

• Screening for human T-cell lymphotropic virus (HTLV)-I and hepatitis C; such screening is recommended, particularly in areas of high seroprevalence
• Diabetic screening as indicated
• Complete urine analysis with screening for infection
• Group B streptococcal (GBS) carriage cultures (rectal and introital)
• Maternal serum-alpha fetal protein (MS-AFP) as indicated (16 to 20 weeks gestation)
• Toxoplasmosis, cytomegalovirus, and herpes screening tests as indicated
• Electrocardiogram (EKG) as indicated

7 Address areas of special concern. In the physical examination of pregnant, substance-using women, the following areas need special attention:

• Dermatologic: Presence of infections, abscesses, thrombosed veins, herpes infections, pyodermas, icterus, tattoos, bruising (as evidence of battering)
• Dental: Status of dental hygiene, existence of pyorrhea or abscessed cavities
• Otolaryngeal: Presence of rhinitis, excoriation of nasal septum
• Respiratory: Presence of wheezes, rales; signs of interstitial pulmonary disease
• Cardiovascular: Rate and rhythm abnormalities, presence of murmurs
• Gastrointestinal: Presence of hepatomegaly, scars from injuries, incisional or umbilical hernias
• Genitourinary: Presence of infections such as condyloma acuminatum, herpes vulvovaginitis, trichomonas vaginitis, bacterial vaginitis, and gonorrheal/chlamydial urethritis/cervicitis; condition of the uterus, including size configuration, fetal position, fetal heart rate, and fetal activity
• Breast: Nipples, evidence of trauma, "lumps or bumps," breast vein used for injection
• Musculoskeletal: Evidence of pitting edema, distortion of muscular landmarks due to subcutaneous abscesses, or brawny edema
• Lymphatic: Presence of lymphadenopathy and abscesses

8 Address medical complications. Complications encountered in pregnancy that require special attention include

• Anemia
• Bacteremia/septicemia
• Cardiac disease, especially endocarditis
• Cellulitis
• Poor dental hygiene
• Edema
• Hepatitis, acute and chronic
• HIV infection
• Phlebitis
• Pneumonia
• Tetanus
• Tuberculosis
• Urinary tract infection, including cystitis, urethritis, and pyelonephritis
• Sexually transmitted diseases, including condyloma acuminatum, gonorrhea, herpes, syphilis, chlamydia, and other vulvovaginitides