High Risk Obstetrics: A Joint Venture

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High Risk ObstetricsA Joint Venture

• Maj Jessica Mitchell
• Dept of Family Medicine
• Travis AFB, CA

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Objectives

• Discuss the importance
• Example-Gestational Diabetes
• Example-Chronic Hypertension
• How to have joint
• relationship with
• our Obstetric colleagues

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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

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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

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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

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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

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• 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.

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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

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How to Diagnose

• Clinical history
• Low risk factors
• Age lt25
• BMIlt25
• 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

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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

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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

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GDM Treatment

• Diet
• No studies just on diet or how long to try prior
  to meds
• ADA does recommend those with BMIgt30 have caloric
  restriction- outcomes similar to matched controls
• Exercise
• No data
• Will help with weight and cardiopulmonary
  condition

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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

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How to check sugars

• Fasting and postprandial (1 or 2 hour)
• Fasting lt 95
• Small study group glucose lt95, and glucose 95-105
• 29 LGA diet and 10 LGA if insulin to keep
  fastinglt95
• 1 hour postprandiallt140
• 2 hour postprandial lt120
• Most studies done on preexisting diabetics

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? 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

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? Fetal Surveillance

• Ultrasound
• No study on routine ultrasound on EFW
• No study on routine serial ultrasound

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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

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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

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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

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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

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What to do first visit

• Preconception counseling would be best
• Assess end organ damage
• Baseline labs for preeclampsia
• Decide about treatment

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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 gt180/110 will change outcomes

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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)

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Fetal Surveillance

• No RCT- consensus
• Serial ultrasound for growth
• APFT for growth concerns
• Possible early delivery at 39 weeks

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Postpartum Follow-up

• Individualize
• ? Meds
• ? How often to follow-up
• ? Other tests needed

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• 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

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One-at-a-time

• Get one patient and call the obstetrician, maybe
  once, maybe every visit
• Time consuming

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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

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Grandfathered In

• After one or two patients the obstetricians dont
  want to hear about
• Works well in busy small places where easy
  contact if needed

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Formal Consults

• Little more structured
• Risk of losing the patient
• Must set agreed upon rules about which diagnoses
  and how often

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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

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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.
  1989161646-653.
• 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. 19953331237-41.
• Danilenko-Dixon et al. Universal versus selective
  gestational diabetes screening application of
  1997 American Diabetes Association
  recommendations. Am J of Ob and Gyn.
  1999181798-802.

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References

• ACOG Technical Bulletin. Chronic Hypertension in
  Pregnancy. Number 29. July 2001.
• Landon et al. Antepartum fetal surveillance in
  gestational diabetes mellitus. Diabetes. 198534
  (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.
  1990162960-966.
• Von Dadelszen et al. Fall in mean arterial
  pressure and fetal growth restriction in
  pregnancy hypertension a meta-analysis. Lancet.
  200035587-92.