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1. Evidence Based Prenatal Counseling and Care Kristen Wyrick, Capt, USAF, MC
David Grant Medical Center
Travis AFB, California
2. The Goal
3. Overview Pre-Conception Counseling
Prenatal Counseling
Iron Supplementation
Rubella
HSV
Urinalysis
Ultrasound
4. Prenatal Care Average number of prenatal visits 7-11
20% of patients present >13 weeks gestation
Reduced visits associated with less satisfaction, not associated with increased adverse outcomes*
Family Medicine care as effective as OB/Gyn*
More patient satisfaction from Family Medicine Physicians than from Obstetricians*
5. Pre-Conception Counseling Screen all reproductively capable women
50% of all pregnancies are unintended
Determine if pregnancy is desired
Goal is to optimize the health of every woman
Identify women at high risk for an adverse pregnancy outcome
Reduce the risk to both mother and fetus
6. The Developing Fetus
7. Topics to discuss Medical conditions
Immunization history
Medications
Nutritional issues
Family history
High-risk behaviors
Occupational exposures
8. Medical Conditions Diabetes
PKU
Lupus
Autoimmune Disorders
9. Overview Pre-Conception Counseling
Prenatal Counseling
Iron Supplementation
Rubella
HSV
Urinalysis
Ultrasound
10. Prenatal Counseling Diet
Substance Use
Workplace conditions
Air Travel
Exercise
Medications
Breast Feeding
11. Strength of Recommendation Grades A- Consistent, good-quality patient-oriented evidence
B- Inconsistent or limited-quality patient-oriented evidence
C- Consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening
12. Air Travel Flying is generally safe throughout pregnancy until 4 weeks prior to the EDC*
Level C Recommendation
Extended trips are associated with increased risk of DVT.
Patients should get up every 30 min
No evidence that the radiation from Security increases risk of adverse outcomes
13. Exercise and Wt Gain 30 min of moderate exercise most days*
Level C recommendation
Avoid abdominal trauma and scuba diving
Obesity and Increased wt gain (>25 lbs) associated with increased risk of
Preeclampsia
Macrosomia
SGA
Cesarean Section
Infant mortality not linked to maternal wt gain
Multi-center prospective study of over 16,000 patients showed statistically significant rates of above outcomes for each class of obesity and wt gain.Multi-center prospective study of over 16,000 patients showed statistically significant rates of above outcomes for each class of obesity and wt gain.
14. Breastfeeding Best form of nutrition for the infant
Structured behavior counseling and education programs increase success*
Level B recommendation
Insufficient evidence to show provider affect on breast feeding success.*
15. Overview Pre-Conception Counseling
Prenatal Counseling
Iron Supplementation
Rubella
HSV
Urinalysis
Ultrasound
16. Maternal Iron Deficiency Anemia Routine Screening for Iron Deficiency Anemia
Level B recommendation
Increased risk of low birth weight infant, preterm delivery and perinatal mortality
Associated with postpartum depression and poor test performance in offspring
17. Iron Supplementation Increases hemoglobin and serum ferritin levels
Reverses drop in hemoglobin in 2nd trimester
Recommended for all anemic pregnant women
Insufficient evidence to support treating all non-anemic pregnant patients.
18. Overview Pre-Conception Counseling
Prenatal Counseling
Iron Supplementation
Rubella
HSV
Urinalysis
Ultrasound
19. Rubella Congenital Rubella Syndrome
Incidence 0.1 per 100,000
Cluster outbreaks, especially among foreign born patients
IgG best serology for immunity
MMR should be given post-partum, safe in breastfeeding CRS- Cataracts, congenital glaucoma, heart defects, deafness, mental retardation, bone diseaseCRS- Cataracts, congenital glaucoma, heart defects, deafness, mental retardation, bone disease
20. Overview Pre-Conception Counseling
Prenatal Counseling
Iron Supplementation
Rubella
HSV
Urinalysis
Ultrasound
21. HSV 22% of pregnant women have HSV-2
90% are asymptomatic/undiagnosed
2% of pregnant women will acquire HSV
Neonatal herpes is a severe complication
Rates of severe sequelae and incidence of HSV have not improved despite advances in testing and treatment
22. HSV Testing Counseling most important for discordant couples
USPSTF currently recommends against routine screening
Level D recommendation
Testing of patient and spouse may become standard of care
23. HSV Treatment Antiviral therapy
First clinical episode
Recurrent episodes
Suppressive therapy
Suppressive therapy for the partner
Topical therapy not affective
24. Overview Pre-Conception Counseling
Prenatal Counseling
Iron Supplementation
Rubella
HSV
Urinalysis
Ultrasound
25. Urinalysis Reagent Test Strips
Used to detect
Asymptomatic bacteriuria
Proteinuria
Glucosuria
Thought to prevent pre-eclampsia, pyelonephritis and early detection of diabetes
26. Dipping Urine at each antenatal visit Not recommended for detection of proteinuria or glucosuria but may be useful to detect some patients with asymptomatic bacteriuria
Level C recommendation
Only detects gram negative bacteria
In normotensive women, urine dipstick does not provide any clinically useful information regarding pregnancy outcome
27. Ultrasound
28. Ultrasound Better diagnostic modality than a screening tool
More accurate than LMP at determining EDC when performed in the first trimester*
A Cochrane review found reduced rates of induction of labor for post-term pregnancy
USPSTF recommends against routine use in 2nd trimester
29. Summary Counsel all females of reproductive age
Prenatal Counseling takes time, should be done over several visits
Screen all pregnant patients for anemia and encourage compliance with Ferrous Sulfate
Rubella titer most useful before your patient is pregnant
30. Summary HSV testing may become standard of care
Urine dipstick only useful for detecting asymptomatic bacteriuria
Consider doing first trimester ultrasound for dating on initial visit, second trimester ultrasound optional
31. Family Medicine Physicians provide comprehensive and effective prenatal care
32. References Villar J, et al. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD000934
Behavioral interventions to promote breastfeeding: recommendations and rationale. Ann Fam Med 2003;1:79-80.
Gribble RK - The value of routine urine dipstick screening for protein at each prenatal visit. Am J Obstet Gynecol - 01-JUL-1995; 173(1): 214-7
Helfand M, Freeman M, Nygren P, Walker M. Screening for Iron Deficiency Anemia in Childhood and Pregnancy: Update of 1996 USPSTF Review. Evidence Synthesis No. 43
Kirkham, C. Harris, S. Gryzbowski, S. Evidence-Based Prenatal Care: Part I & 2 AFP April 1 & 15, 2005; vol 71, number 7: 1307-1316.
Waugh JJ; Clark TJ; Divakaran TG; Khan KS; Kilby MD Accuracy of urinalysis dipstick techniques in predicting significant proteinuria in pregnancy. Obstet Gynecol 2004 Apr;103(4):769-77.
Mongelli M; Wilcox M; Gardosi Estimating the date of confinement: ultrasonographic biometry versus certain menstrual dates. J Am J Obstet Gynecol 1996 Jan;174(1 Pt 1):278-81.
Neilson JP Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev 2000;(2):CD000182.
ACOG Committee on Obstetric Practice. ACOG committee opinion. Exercise during pregnancy and the postpartum period. Number 267, January 2002. Int J Gynaecol Obstet 2002;77:79-81.
American College of Sports Med. ACSM’s guidelines for exercise testing and prescription. 6th ed. Philadelphia: Lippincott, Williams and Wilkins, 2000
Weiss JL, et al. Obesity, obstetric complications and cesarean delivery rate- a population-based screening study. FASTER Research Consortium. Am J Obstet Gynecol 2004; 190: 1091-7.
Reef SE, et al. The changing epidemiology of rubella in the 1990’s: on the verge of elimination and new challenges for control and prevention. JAMA 2002; 287: 464-72
Brown ZA, et al. Genital Herpes Complicating Pregnancy. Obstetrics & Gynecology. 106(4):845-856, October 2005.