The following was initially shared as a CME session presented by Dr. Nihal El Khouly, MD, CCFP, FCFP.
Delivering consistent and effective prenatal care is foundational for favorable maternal and fetal health outcomes. However, many in our region often present past 30 weeks of gestation with no established clinical supports. Consequently, it places stress on patients to navigate their pregnancy without adequate health supports ultimately increasing clinical risk. Attaching patients to health providers, who often have little to no remaining patient list space, remains a concern and this places strain on the healthcare system to provide late intervention care.
Prenatal care requires a structured and coordinated approach to provide services, and this guide is intended to provide information on essential phases of care, areas of prioritization, accurate assessments, and effective transitions of care.
First Trimester – Establishing Early Care
Early pregnancy care is focused on confirmation, risk mitigation, and support planning. Conducted around 6-10 weeks, the initial prenatal visit is necessary for confirming a clinical baseline. A full medical history and physical examination is necessary to screen for maternal and fetal risks to inform additional tests, guide subsequent management, and to promote preventive interventions. Providers must also advise patients on critical lifestyle factors including diet, appropriate supplements, and safe medications. A critical objective during this stage is to transfer the patient to a Primary Care Obstetrics Group (PCOG) or Obstetrician.
A dating ultrasound is performed during this period as well, this will allow providers to confirm viable intrauterine pregnancy (IUP), determine accurate gestational age, and estimated due date. Assessing the fetal heartbeat and number of fetuses are also conducted. Through a transvaginal ultrasound key indicators like the gestational sac and fetal pole are visualized, and this requires clinical observation to observe any potential subchorionic hemorrhage, corpus luteal cysts, anembryonic pregnancy or embryonic demise, which must be addressed with specific care interventions.
Second Trimester – Screening and Fetal Surveillance
Once the pregnancy is established and early care is conducted the focus is shifted towards risk assessment, and patients must be counselled on their screening options through the course of their pregnancy. Options include Enhanced First Trimester Screening (eFTS) and Second Trimester Maternal Serum Screening (MSS). Non-invasive Prenatal Testing (NIPT) is a high specificity form of screening available after 10 weeks and is covered for high risk individuals in Ontario. Amniocentesis screening is available between 10-15 weeks to definitively determine any chromosomal or genetic conditions, precursors to prompt this test include any positive prenatal observations, familial history of conditions, or maternal age over 40. An anatomy scan is conducted around 18-22 to check for major fetal anomalies, assess the placental position, examine the cervix, and the volume of the amniotic fluid.
Patients with risk of Preeclampsia Prophylaxis are prescribed a plan of low dose Aspirin. Risk factors include nulliparity, prior stillbirth, intrauterine growth restriction, and older maternal age. Higher risk factors include a prior history of preeclampsia, renal disease, autoimmune disease, or a pre-pregnancy BMI greater than 30. Low dose Aspirin is generally prescribed between 12-16 weeks and continued daily until delivery for optimal effectiveness.
Pregnancy medical conditions often require referrals to specialists, specialized care plans, and medication treatments, common conditions include:
| Hypertension | Diabetes |
| Liver disease | Rheumatology |
| Thyroid disease | Kidney disease |
| HIV | Seizures |
| Hepatic disease | LMW heparin |
| Asthma | Heart disease |
Third Trimester – Late Stage Monitoring
The Oral Glucose Challenge Test (OGCT) and Oral Glucose Tolerance Test (OGTT) are performed at approximately 24 weeks to screen for gestational diabetes, but higher risk patients require earlier screening. Haematological screens check ferritin, iron, and vitamin B12 levels, and also antibody screens determine the need for a Rhogam injection.
In cases of preterm labour there are multiple symptoms providers should inform patients to be aware of to minimize complications. These include low persistent backache or thigh pain, pelvic pressure, vaginal discharge/bleeding, and irregular contractions.
In unfortunate circumstances where pregnancy loss is diagnosed providers must be prepared to offer compassionate support and referrals for counselling. Depending on individual medical circumstances options are discussed with the patient. Expectant management allows a miscarriage to progress naturally, letting the pregnancy tissue pass from the body on its own without medication or surgical intervention. Medical treatment requires a medication regimen, commonly, Mifegymiso is prescribed which blocks progesterone and uses prostaglandin for uterine contraction to expel pregnancy tissue. Long lasting heavy vaginal bleeding, severe cramps, and fever require patients to visit the ED. Also, a short surgical procedure is an option for patients to remove pregnancy tissue.
Pregnancy is a unique and special process and to ensure proper care is practiced during this time it requires the coordination between patients, healthcare providers, and health programs. To stay up to date and informed helpful links to resources are available below.
Pregnancy Tools
Resources
English 