Routine Antepartum Care

1. Routine Antepartum Care Rita W. Driggers, MD Associate Professor of Gynecology and Obstetrics Johns Hopkins University School of Medicine

2. Objectives • At the conclusion of this session, attendees will summarize: • Timing of appointments and tests/topics to be addressed at each prenatal visit for the uncomplicated pregnancy • Current recommendations involving the following in the setting of pregnancy: • Diet and weight gain • Exercise • Travel and travel prophylaxis • Immunizations • Tobacco, alcohol, and caffeine use • Psychiatric medications

3. 29yo G0 presents for routine health maintenance and informs you she would like to conceive in the next year. H&P are unremarkable. She states she eats a well balanced diet but enjoys and has become accustomed to having 3 lattes each morning and 2 glasses of wine with dinner each night.

4. At this time you would advise the patient: • She should quit drinking lattes now because increased caffeine intake is associated with recurrent pregnancy loss • She can continue to have her lattes now but should stop or cut down once pregnant because increased caffeine intake is associated with IUGR • She can continue to drink lattes but should limit caffeine intake to 200mg/d preconceptionally and during the 1st trimester

5. At this time you would advise the patient: • 1oz of alcohol (1 beer, 1 glass of wine, 1 single-shot mixed drink) per day in the 2nd or 3rd trimester, but not in the 1st trimester, has been shown to be safe in pregnancy • No level of alcohol use, even the most minimal drinking, has been determined to be absolutely safe in pregnancy • Alcohol-related adverse pregnancy outcomes include spontaneous abortion, nervous system impairment, birth defects, and fetal alcohol syndrome

6. Caffeine and Pregnancy • Conflicting reports whether increased caffeine intake is associated with spontaneous miscarriages • Not believed to be a cause of recurrent pregnancy loss • Recent study suggests intake >200mg/day (approximately 10oz coffee or 25oz tea) doubles the risk of 1st trimester miscarriage (24.5%) • In non-smokers, caffeine use has not been shown to be associated with intrauterine growth restriction in amounts up to 4000mg per week • Caffeine ingestion temporarily increase blood pressure • Should not be ingested 30 minutes prior to vitals • Used judiciously if pregnancy complicated by hypertension

7. Alcohol Use and Pregnancy • Fetal alcohol syndrome (FAS) - leading cause of mental retardation in United States • 12% of pregnant women admit to drinking some alcohol during the previous month • No level of alcohol use, even the most minimal drinking, has been determined to be absolutely safe during pregnancy • Abstinence is the only known way to avoid all alcohol-related adverse pregnancy outcomes • Spontaneous abortion • Nervous system impairment • Birth defects • FAS

8. Routine Prenatal Care • Goal of antepartum care is to reduce risk of adverse health effects for the woman, fetus, and neonate • For low risk patients, the VA/DoD Clinical Practice Guideline for Management of Uncomplicated Pregnancy may be followed • Patient evaluated at 6-8 weeks • Initial labs drawn • Risk factors that may impact pregnancy identified • Appropriate referrals made • Patient assigned to routine or high risk obstetric care

9. Routine Prenatal Care • If uncomplicated, subsequent appointments at • 10-12 weeks • 16-20 weeks • 24 weeks • 28 weeks • 32 weeks • 36 weeks • weekly beginning at 38 weeks • Instruct patient where to be seen for complications that cannot wait until next scheduled appointment to be addressed

10. A 33yo G3P2002 presents for her initial OB evaluation. She states she was never able to lose all the weight she gained in her prior pregnancy (60lbs) and wants your recommendation for weight gain during this pregnancy.

11. You calculate her BMI to be 28kg/m2. Which of the following is/are true? • The patient is of normal weight and should gain 25-35lbs • The patient is overweight and should gain no more than 15-25lbs • The patient is obese and should limit her weight gain to no more than 15lbs • The patient is obese and should be followed by your partner

12. Obese women are at increased risk of which of the following pregnancy complications: • Cesarean delivery • Congenital anomalies • Gestational hypertension • Preeclampsia • Gestational diabetes

13. Obesity and Pregnancy • Institute of Medicine recommended weight gain during pregnancy • BMI <18.5 kg/m2 (underweight): 28 to 40 lbs • BMI 18.5 to 24.9 kg/m2 (normal weight): 25 to 35 lbs • BMI 25.0 to 29.9 kg/m2 (overweight): 15 to 25 lbs • BMI ≥30.0 kg/m2 (obese):11 to 20 lbs (5 to 9.0 kg) • Obese women are at increased risk for • Gestational hypertension • Preeclampsia • Gestational diabetes • Cesarean delivery

14. Obesity and Pregnancy • Ideally, encourage obese patients to begin a weight loss program prior to attempting to conceive • Diet, exercise, and behavior modification • Nutrition counseling should be offered to all obese women • Encourage to follow an exercise program • Consider early gestational diabetes screening • Repeat screening later in pregnancy if early results negative • If delivered by cesarean section • Early ambulation • Hydration • Use of graduated compression stockings

15. After counseling your patient about risks of obesity in pregnancy, she decide she wants to start exercising. You advise her: • In the absence of either medical or obstetric complications, 30 minutes or more of moderate exercise per day on most, if not all, days of the week is recommended • Participation in wide range of exercise programs and recreational activities during pregnancy is safe • Exercise at altitudes up to 6,000 feet safe • Scuba diving should be avoided

16. Exercise in Pregnancy • Each activity evaluated for potential risks (eg, falling or abdominal trauma) • Absolute contraindications to aerobic exercise: • Hemodynamically significant heart disease • Restrictive lung disease • Incompetent cervix • Preterm labor • Ruptured membranes • Preeclampsia or pregnancy induced hypertension • Persistent 2nd or 3rd trimester bleeding • Placenta previa • Multiple gestation

17. Exercise in Pregnancy • Relative contraindications to aerobic exercise: • Severe anemia • Unevaluated arrhythmia • Chronic bronchitis • Extreme morbid obesity • Extremely sedentary lifestyle • Extreme underweight (BMI <12) • Poorly controlled hypertension, hyperthyroidism, seizures • Brittle Type 1 diabetes • Orthopedic limitations • Heavy smoking

18. Exercise in Pregnancy • Warning signs to terminate exercise: • Vaginal bleeding • Dyspnea prior to exertion • Dizziness, headache, chest pain • Muscle weakness, calf pain or swelling • Preterm labor • Decreased fetal movement • Amniotic fluid leakage

19. Exercise in Pregnancy • Following delivery • Pre-pregnancy exercise routines may be resumed gradually • Some may resume exercise routine within days, others may take 4-6 weeks • Return to physical activity after pregnancy associated with decreased incidence of postpartum depression

20. Initial OB Visit (10-12 weeks) • Review and record all initial labs • Blood type, Rh and antibody screen • CBC • Hemoglobin electrophoresis if indicated • UA, urine C&S • RPR, Rubella titer, HIV, HBsAg • Address significant abnormalities and list on problem list

21. Initial OB Visit (10-12 weeks) • Review of systems and medical history with emphasis on items that may impact OB management • Teratogen exposure, smoking, ETOH, drug and medication use • History of genital herpes, STD, and patient occupation/exposures • Blood transfusions/blood products • Diabetes • Seizure disorders • SLE • Family medical history with emphasis on • Diabetes • Chronic hypertension • Collagen vascular diseases • Genetically inherited diseases/teratology • Genetic counseling if indicated

22. Initial OB Visit (10-12 weeks) • Record any notable symptoms since LMP • Perform and record a complete physical exam • Cervical swab for chlamydia and gonococcus testing and Pap • Breast examination • Evaluate uterine size • Perform clinical pelvimetry • Diagonal conjugate estimated by inserting 2nd and 3rd fingers into vagina measuring the distance from sacral promontory to the lower margin of symphysis pubis • Adequate diagonal conjugate is >11.5cm • Document assessment, follow-up plan, and any indicated special procedures

23. Initial OB Visit (10-12 weeks) • Patient problem list utilized for • Calling attention to problems • Addressing special management plans • List current medications on a medication list • Document allergies to medications and type of reaction • If previous Cesarean delivery or uterine surgery • Get details of indication and type of uterine scar • Review operative report and place a copy in chart • If candidate for a trial of labor (TOL), counsel as to risks and benefits

24. Initial OB Visit (10-12 weeks) • Cystic fibrosis (CF) and maternal serum screening counseling • Indications for nutrition counseling: • Underweight mothers • Morbid obesity • Poor weight gain • Eating disorders • History of nutritional deficiencies or anemia • Vegetarians • Teen mothers • Weight reduction surgery (gastric bypass, etc.)

25. A 33yo G1P0 presents for her 10 week antepartum appointment. She reports her sister delivered at 28 weeks and wants to know what can be done to screen for preterm birth during her pregnancy

26. You would recommend to this patient: • Home uterine activity monitoring later in pregnancy • Frequent evaluations for bacterial vaginosis • Serial fetal fibronectin tests • Cervical length measurement

27. Screening for Preterm Birth • Infants born prematurely have increased morbidity and mortality • One of the strongest clinical risk factors for preterm birth is a prior preterm birth • Other factors associated with increased risk of PTB • Vaginal bleeding • Urinary tract infections • Genital tract infections • Periodontal disease • Treatment not shown to decrease risk

28. Screening for Preterm Birth • Fetal fibronectin • Extracellular matrix glycoprotein • Marker for disruption of chorioamnion and underlying decidua • Negative test useful in ruling out PTB • Negative predictive value for delivery <37 weeks: 69-92% • Negative predictive value for not delivering within next 14 days: >95%

29. Screening for Preterm Birth • ACOG Practice Bulletin #130, October 2012 • Tests such as fetal fibronectin screening, bacterial vaginosis testing, and home uterine activity monitoring are not recommended as screening strategies • Short cervical length measured by transvaginal ultrasonography has been associated with increased risk of preterm birth • Cervical length screening strategy may be considered

30. 16-20 Week Visit • Offer 2nd trimester maternal serum screening • At this and each subsequent visit • Blood pressure • Weight gain • Fundal height • Fetal heart tones

31. 16-20 Week Visit • The following warrant further evaluation: • Blood pressure > 140 systolic • Blood pressure > 90 diastolic • Urine protein > 1+ • Vaginal bleeding • Loss of fluid per vagina • Lack of fetal movement if over 20 weeks gestation

32. 16-20 Week Visit • Sonographic evaluation of fetal anatomy at 16-20 wks • Document • Presence or absence of fetal movement • Time of next follow-up visit • Discuss management plans • Patient education topics should include • Breastfeeding • Exercise • Vaccinations • Family planning • Domestic abuse

33. 27yo G2P1 at 16+0 weeks wants to get up to date on her immunizations. She has no chronic medical problems. Which are NOT contraindicated in pregnancy: • Measles • Mumps • Polio • Anthrax • Influenza nasal vaccine • Influenza IM vaccine

34. Immunizations/Travel Prophylaxis • Current information on safety of vaccines during pregnancy subject to change • Centers for Disease Control and Prevention web site at www.cdc.gov/vaccines/ • Currently, only live attenuated virus vaccines are contraindicated • Measles, mumps, rubella • Poliomyelitis • Yellow fever • Varicella

35. Immunizations/Travel Prophylaxis • Influenza • Administer to women pregnant during the influenza season (October through May) • Intranasal influenza vaccine spray contains a live, attenuated virus • Intramuscular inactivated vaccine should be used • Vaccination of women susceptible to rubella and varicella should be encouraged postpartum • Typhoid and Hepatitis A vaccinations recommended for pregnant patients traveling to endemic areas • Anthrax vaccination recommended to pregnant women who work directly with B anthracis or military personnel deployed to high-risk exposure areas

36. 24 Week Visit • Signs/symptoms of preterm labor • Fetal kick counts • Symptoms of preeclampsia • Other patient education topics • Breastfeeding • Exercise • Vaccinations • Family planning • Domestic abuse

37. At her 24 week appointment your patient confides that she was treated with sertraline for postpartum depression following her last delivery but discontinued it prior to attempting to conceive due to concerns for teratogenicity.

38. Recently she has become more depressed but is concerned about the effects of sertraline on the fetus. You inform her that • It would be preferable to treat her with 2 antidepressants at a lower dose • The major risk of teratogenesis is during the 3rd – 8th weeks of gestation • SSRIs have been associated with increased risk of cardiac defects in exposed fetuses but paroxetine is preferred over sertraline • If she wants to be depressed she should look at your clinic schedule and you don’t have time to deal with this

39. Psychiatric Medications in Pregnancy • Inadequately treated maternal psychiatric illness • Poor compliance with prenatal care • Poor nutrition • Self-medication • Increased alcohol or tobacco abuse • Inadequate maternal-infant bonding • Disruptions to the home environment • Discontinuing psychiatric medications exchanges fetal risks of medication exposure for risks of untreated maternal psychiatric illness • A single medication at a higher dose is preferred over multiple medications

40. Psychiatric Medications in Pregnancy • Teratogenesis • Major risk during embryogenesis (3rd – 8th weeks) • Patient with mild illness • If medication is known to be teratogenic, consider tapering before conception • If necessary, reinstitute after organogenesis • Patient with severe illness • Continue medication throughout gestation • Counsel the patient about the risks • Order studies (targeted anatomic survey, fetal echocardiogram) to evaluate fetus

41. Psychiatric Medications in Pregnancy • Treatment with selective serotonin reuptake inhibitors (SSRIs) or selective norepinephrine reuptake inhibitors • Should be individualized • Paroxetine use increases risk of cardiac defects in exposed fetuses and should be avoided • Lithium, valproate, and carbamazepine are associated with an increased risk of fetal anomalies and should be avoided, especially during organogenesis

42. 28 Week Visit • 28 week labs • CBC • Blood type, Rh and antibody screen • Glucola screen • Rhogam • Rh negative, non-immunized patients • Following any procedure/complication which places the patient at risk for fetal-maternal bleed

43. 28 Week Visit • Diabetes screening • Oral 50 gram glucola challenge followed by serum glucose level in one hour • Should be performed on any new OB patients with • History of macrosomia (greater than 4500 grams) • Unexplained stillbirth • Prior child with a congenital anomaly • Family history of diabetes • Maternal obesity • Persistent maternal glycosuria • Alternatively, screen all patients at 24-28 weeks • Abnormal result followed up with 3 hour OGTT

44. You call your patient to inform her that she has 2 abnormal values on her 3hr OGTT and that you will be referring her for dietary counseling and teaching on home glucose monitoring. She gets upset and states she believes she is diabetic because she quit smoking for the pregnancy but gained 50 lbs as a result. She states that the only way she can be compliant with the ADA diet is to resume smoking.

45. You inform her that she should not smoke because this will increase her risk of adverse pregnancy outcomes to include: • Abruption • Fetal growth restriction • PROM • Previa • Ectopic pregnancy

46. You also inform her that children born to smokers are at increased risk for: • SIDS • Childhood obesity • Infantile colic • Asthma

47. Tobacco Abuse in Pregnancy • One of most important modifiable causes of poor pregnancy outcomes • Maternal smoking results in: • Fetal hypoxia from increased carboxyhemoglobin • Reduced blood flow to the uterus, placenta, and fetus • Direct effects of nicotine and other compounds in tobacco on placenta and fetus • Nicotine gum, lozenges, patches, inhalers, and antidepressants that reduce withdrawal symptoms should be considered during pregnancy and lactation when non-pharmacologic treatments failed

48. Tobacco Abuse in Pregnancy • The 5A’s of intervention (adapted from the U.S. Public Health Service clinical practice guideline): • Ask about smoking status • Advise by providing clear, strong advice to quit with personalized messages about the benefits of quitting and the impact of continued smoking on patient, her fetus, and newborn • Assess willingness of the patient to quit • Assist by suggesting and encouraging use of problem-solving methods and skills for smoking cessation • Arrange follow up visits to track progress

49. 32 Week Visit • Review 28 week labs • Address any patient concerns/complaints • Re-address • preterm labor • preeclampsia • fetal kick count precautions

50. At her 32 week visit, your patient tells you that she plans to take an international flight. Her pregnancy has been uncomplicated. You inform her: • She is beyond the EGA cut off for most international airlines • The reduced humidity in the airplane cabin causes hemoconcentration which increases risk for venous thrombosis • Periodic movement, support stockings, and hydrating may decrease risk of thrombosis • She can travel but should use supplemental oxygen during the flight