High Risk Obstetrics: A Joint Venture

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.