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1. High Risk Obstetrics:A Joint Venture Maj Jessica Mitchell
Dept of Family Medicine
Travis AFB, CA
2. Objectives Discuss the importance
Example-Gestational Diabetes
Example-Chronic Hypertension
How to have joint
relationship with
our Obstetric colleagues
3. Some High Risk Statistics Pregnancy induced hypertension 37/1000
Anemia 23.8/1000
Gestational Diabetes 32.8/1000 **
Chronic Hypertension from 6.5 to 8.8/1000
Lung Disease from 3.0 to 12.1/1000
4. Why is it confusing? What is the agreed upon list of High Risk Diagnoses
How many times does a High Risk OB patient need to be seen by obstetrician
Is the patient comfortable seeing and FP doc for their pregnancy
Ware the outcomes different for High Risk patients seeing OB vs FP docs
5. High Risk Diagnosis Chronic Hypertension
Gestational Diabetes
Thyroid disorders
Mood disorders
Seizure disorders
SLE
Asthma
Prior preterm delivery Prior stillbirth
Multiple gestation
Significant cardiac disease
Prior renal disease
Preexisting diabetes
Social issues
6. Other factors Litigation patterns
Experience
What your comfort level is
Amount of obstetric back-up
Upper management role
Our personal drive or love of the practice
7. 22 y/o G1P0, your patient for 3 years, gets pregnant. You are following her through her pregnancy and develop even deeper relationship. AT 27 weeks she has and elevated glucola. You order a 3 hour glucola and it has 3 abnormal values. You send her that week to be followed by the obstetrician.
8. How to diagnose GDM ACOG recommend that every woman should be screened
USPHS states insufficient evidence for universal screening but screening high risk patients would be beneficial
9. How to Diagnose Clinical history
Low risk factors
Age <25
BMI<25
No history prior glucose intolerance
No previous adverse obstetric outcome associated with GDM
No first degree relative with DM
Ethnic group NOT high risk for DM II
Only 3% of GDM would be missed
Only 8-10% people would be excluded from testing
10. How to Diagnose GDM 1973- 50 gm glucola was developed
? Cutoff 130 or 140
When to perform the test-conflicting interests
When do you perform early screening
Elevated BMI, prior GDM (33-50% recurrence), family history, macrosomic infant in past
Although no studies to demonstrate universal lab testing decrease complications, almost 95% obstetric practices perform routinely
11. How to diagnose GDM Confirm with 3 hour GTT
2 sets of abnormal values
2 out of 4 values must be elevated
1 abnormal does have slight increase risk macrosomia
12. GDM Treatment Diet
No studies just on diet or how long to try prior to meds
ADA does recommend those with BMI>30 have caloric restriction- outcomes similar to matched controls
Exercise
No data
Will help with weight and cardiopulmonary condition
13. GDM Treatment Insulin
Any regimen that controls glucose
Routine glucose monitoring, individual frequency
Oral
Glyburide not recommended by ACOG
Studies do demonstrate effectiveness- 80% effectively controlled with 7.5 mg or less
14. How to check sugars Fasting and postprandial (1 or 2 hour)
Fasting < 95
Small study group glucose <95, and glucose 95-105
29% LGA diet and 10% LGA if insulin to keep fasting<95
1 hour postprandial<140
2 hour postprandial <120
Most studies done on preexisting diabetics
15. ? Fetal Surveillance Antepartum fetal testing
Preexisting diabetics have increased risk of fetal demise-? For GDM
Very little data
Recommended that if on medication do biweekly NST and weekly AFI- No stillbirth but 4.9% risk c-section
Cohort of diet controlled- daily kick counts from 28 weeks and APFT at 40 weeks – no stillbirths
16. ? Fetal Surveillance Ultrasound
No study on routine ultrasound on EFW
No study on routine serial ultrasound
17. Delivery Decisions Timing
Diet controlled- no reason prior to 40 weeks
Medication controlled- many induce at 39 weeks but no absolute indication
Study at 38-39 weeks-1.4% vs 10% risk shoulder dystocia but no change in macrosomia or c-section
Method
No data or consensus about EFW and definite c-section
? 4500 grams ? 4000 gms NO operative delivery
18. Postpartum Follow-up Up to 50% will develop DM in their lifetime
Fasting vs 75 gm 2 hour GTT
2 hour GTT more predictive of those at risk later in life of developing DM
Any screen is accepted, 6 weeks postpartum for convenience
19. Chronic Hypertension-Diagnosis Hypertension prior to pregnancy
Hypertension seen in first 20 weeks of pregnancy
Hypertension persisting after 12 weeks postpartum
Multiple confusing factors to include late entry to care, pre-eclampsia
20. Chronic Hypertension Complications well documented
1/3 with severe HTN have SGA infants
2/3 with severe HTN have preterm delivery
If develop preeclampsia up to 2% risk perinatal mortality
Increased risk IUGR, abruption, c-section, fetal demise
21. What to do first visit Preconception counseling would be best
Assess end organ damage
Baseline labs for preeclampsia
Decide about treatment
22. Hypertension Treatment Mild 140-179/90-109
Study of women treated with methyldopa or labetalol had no change in IUGR, abruption, or mortality
? Prior medications
Study where meds left the same-No change in preeclampsia, abruption or mortality but slight increase risk of SGA
For severe >180/110 will change outcomes
23. So what does it mean? Decrease prior medication (might stop) but increase dose if 150-160/100-110
Safe medications include methyldopa and labetalol
Beta blockers slight increase risk of SGA
NO ACE Inhibitors
Diuretics may be used (not preferred)
24. Fetal Surveillance No RCT- consensus
Serial ultrasound for growth
APFT for growth concerns
Possible early delivery at 39 weeks
25. Postpartum Follow-up Individualize
? Meds
? How often to follow-up
? Other tests needed
26. How do we add high risk OB patients to our practice
One-at-a time with OB
Group Practice with conference
“Grandfathered in“
OB consults
27. One-at-a-time Get one patient and call the obstetrician, maybe once, maybe every visit
Time consuming
28. Group practice with conference Regular meeting to discuss and reach consensus on care of high risk patients
Time conscious
Consensus
Allows group discussion
Allows for documentation
Allows fostering collegial relationships
29. “Grandfathered In” After one or two patients the obstetricians don’t want to hear about
Works well in busy small places where easy contact if needed
30. Formal Consults Little more structured
Risk of losing the patient
Must set agreed upon rules about which diagnoses and how often
31. Summary High Risk diagnoses are becoming more common in pregnancy
We know more about these problems than our obstetric colleagues
There are ways to continue to care for these patients if desired
32. References www.cdc.gov, National Vital Statistics Report, Final Birth report 2003
Acog Practice Bulletin, Gestational Diabetes, Number 30, September 2001.
Langer, Levy,et al. Glycemic control in Gestational Diabetes Mellitus- how tight is tight enough. Small for gestational age vs large for gestational age?. Am J of Ob and Gyn. 1989:161:646-653.
Kremer, Duff. Glyburide for the Treatment of Gestational Diabetes. Am J of Ob and Gyn.(2004) 190: 1438-1439.
De Vieciana et al. Postprandial vs preprandial glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. N Eng J of M. 1995;333:1237-41.
Danilenko-Dixon et al. Universal versus selective gestational diabetes screening; application of 1997 American Diabetes Association recommendations. Am J of Ob and Gyn. 1999;181:798-802.
33. References ACOG Technical Bulletin. Chronic Hypertension in Pregnancy. Number 29. July 2001.
Landon et al. Antepartum fetal surveillance in gestational diabetes mellitus. Diabetes. 1985;34 (supplement 2):50-54.
Sibai et al. A comparison of no medication vs methyldopa or labetalol in chronic hypertension during pregnancy. Am J of Am and Ob. 1990;162:960-966.
Von Dadelszen et al. Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: a meta-analysis. Lancet. 2000;355:87-92.