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 gt13 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 106665-6
8
Medical Conditions

• Diabetes
• PKU
• Lupus
• Autoimmune Disorders

Kitzmiller JL et al. JAMA 1991 Feb
13265(6)731-6. Waisbren SE et al. JAMA 2000
Feb 9283(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 200276338-9.
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 (gt25 lbs)
  associated with increased risk of
• Preeclampsia
• Macrosomia
• SGA
• Cesarean Section
• Infant mortality not linked to maternal wt gain

American College of Sports Med. ACSMs
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 2003179-80.
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 1990s 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

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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
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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 Jan174(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 2003179-80.
• 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 Apr103(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 Jan174(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 20027779-81.
• American College of Sports Med. ACSMs
  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 1990s 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.