Evidence Based Prenatal Counseling and Care

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.