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* * Villar J, et al. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2001, Issue 4. Art. No.: CD000934

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 ACOG Committee Opinion No. 313.Obstet Gynecol 2005; 106:665-6

8. Medical Conditions • Diabetes • PKU • Lupus • Autoimmune Disorders Kitzmiller JL et al. JAMA 1991 Feb 13;265(6):731-6. Waisbren SE et al. JAMA 2000 Feb 9;283(6):756-62.

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 Kirkham, C. Harris, S. Gryzbowski, S. AFP April 1, 2005; vol 71, number 7: 1307-1316.

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 * ACOG Committee on Obstetric Practice. ACOG committee opinion. Air travel during pregnancy. Int J Gynaecol Obstet 2002;76:338-9.

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 *American College of Sports Med. ACSM’s guidelines for exercise testing and prescription. 6th ed. Philadelphia: Lippincott, Williams and Wilkins, 2000

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.* * Behavioral interventions to promote breastfeeding: recommendations and rationale. Ann Fam Med 2003;1:79-80.

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 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

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. 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

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 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

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 Brown ZA, et al. Genital Herpes Complicating Pregnancy. Obstetrics & Gynecology. 106(4):845-856, October 2005.

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 Brown ZA, et al. Genital Herpes Complicating Pregnancy. Obstetrics & Gynecology. 106(4):845-856, October 2005.

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 Gribble RK - Am J Obstet Gynecol - 01-JUL-1995; 173(1): 214-7

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 *Mongelli M; Wilcox M; Gardosi J. Am J Obstet Gynecol 1996 Jan;174(1 Pt 1):278-81.

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.