1. Evidence-Based Prenatal care Parts 1 & 2 AFP 1 st and 15 th July 2005 Oguchi Nwosu M.D. Asst. Prof. Emory Family Medicine January 10 th 2008

2. Evidence-Based Prenatal Care: Part 1 General Prenatal care and counselling issues AFP, April 1, 2005 Systematic approach Best evidence Model of informed, shared decision making -Reduced visit schedule- No adverse outcomes - Decreased patient satisfaction - Decreased patient satisfaction -Caregiver continuity- Decreased interventions in labor & improved maternal satisfaction improved maternal satisfaction -Care by midwives/FM/OB- Equally effective, more satisfaction with MW and FM satisfaction with MW and FM

3. Prenatal care First Visit Ideally 1 st trimester Appropriate counseling : Table 1 - First 12 weeks organogenesis Accurate EDD Recommendations for routine prenatal care: Table 2

4. Table 1

6. Table 2

7. Prenatal care Other issues Prenatal education- especially 1 st preg. Domestic violence screen- 3 questions Blood typing- Ab screen & rhogam at 28 weeks if Rhesus neg Other indications for rhogam ? Other indications for rhogam ?

8. Prenatal care Genetic screening Ideally preconception -FH of genetic disorder -Previous fetus/child with GD -Recurrent miscariages -Ethnic grp. disease specific screening (CF, SCA, Tay Sachs, Thal Offer all women triple screen. 16 to 18 weeks (15 t0 20) Women at increased risk offer Amnio/CVS

9. Prenatal care Ultrasound No evidence directly linked to improved fetal outcomes Early USS (b/4 14 weeks) accurately determines gest. – when in doubt. Indications for 1 st trim USS? Indications for 1 st trim USS? Offer USS b/w 18 – 20 weeks for fetal anomaly search

10. Prenatal care Nutrition/Food safety 25 to 35ib weight gain ideal Folic @ from 4 weeks preconception USPSTF – insufficient evidence for or against fe supplementation Caffeine Dairy products Delicatessen foods Meat Raw eggs Seafood

12. Evidence-Based prenatal care: Part 1 3 rd Trim care & prevention of infectious diseases AFP, April 15, 2005 Infectious diseases Gestational diabetes Post-term pregnancy

13. Prenatal care Infectious diseases HIV HIV Recommend to all Retest high risk in 3 rd trimester Informed consent required SYPHILLIS SYPHILLIS Screen all Retest high risk at 28 weeks & at delivery

14. Prenatal care Infectious diseases HERPES SIMPLEX HERPES SIMPLEX Ask patients and partners re hx of genital or orolabial HSV Vertical transmission -- 50% prim, 33% non prim & 0 – 3% recurrent Acquired during passage through birth canal HSV +ve partner- Abstinence, ? Condom use, Antiviral rx for partner Recurrent HSV counsel re acyclovir at term, role of C/S, & avoiding post partum transmission

15. Prenatal care Infectious diseases CHLAMYDIA/GC CHLAMYDIA/GC Screen women < 25 and high risk EFM- universal screening at 1 st visit 1 st & 3 rd trim High risk groups High risk groups < 25 Unmarried women Black women Hx of STD’s New or multiple sexual partners Cervical ectropion Inconsistent use of barrier contraception Women living in comm. with high infection rates

16. Prenatal care Infectious diseases BV BV Screen symptomatic women Screen women at increased risk for preterm labor RUBELLA RUBELLA Universal screening Offer vaccination in the immediate post partum period if non immune

17. Prenatal care Infectious diseases VARICELLA ZOSTER VARICELLA ZOSTER None immune preg. Women exposed- VZ immune globulin None immune- offer post partum vaccination. -Safe while breastfeeding -Safe while breastfeeding -Delay for 3/12 if rhogam -Delay for 3/12 if rhogam HEP B & C HEP B & C Hb s Ag at 1 st visit. If + post natal intervention Women at increased risk of acquiring- can vaccinate while preg. Hep C testing only in women with risk factors

18. Prenatal care Infectious diseases Risk factors for Hepatitis C 1. Prison inmates 2. Injection drug users 3. Exposure to blood or blood products 4. HIV + 5. Elevated AST levels 6. Multiple sexual partners 7. Tattoos

19. Prenatal care Infectious diseases UTI UTI Universal screening by urine culture (12 – 16 weeks) EFM 1 st visit EFM 1 st visitINFLUENZA Offer all women with med conditions that increase risk of complications. (Vac.) Others- offer women who will be in their 2 nd or 3 rd trim during influenza season. No evidence of risk with 1 st trim vaccination

20. Prenatal care Infectious diseases GBS GBS Significant cause on neonatal M & M 10 to 30 % colonization in women Risk factors for neonatal infection x 3 Universal screening with vaginorectal culture at 35 to 37 weeks Women with GBS bacteuria or previous infant with GBS infection do not need screening – rx Pen or Clinda in Labor or ROM

21. Prenatal care Gestational diabetes 2 to 5% Associated with - Hypertensive disorders - Hypertensive disorders - Macrosomia - Macrosomia - Shoulder dystocia - Shoulder dystocia - Increased C/S rates - Increased C/S rates - DM later in life - DM later in life

22. Prenatal care Gestational diabetes (Screening) Controversial- no studies showing improved perinatal outcomes ACOG/ADA recommends at 24 to 28 weeks except ‘low risk’ 94% physicians including EFM- universal screening I hour 50g GCT followed if positive by 3 hour 100g GTT British guidelines recommend against screening A randomized trial of 2,400 women ongoing in US should provide some answers

23. Prenatal care Gestational diabetes (Low risk) <25 Low risk ethnic group Normal pre-pregnancy weight No hx of abnormal glucose metabolism No hx of poor obstetric outcomes No hx of 1 st degree relatives with DM

24. Prenatal care Post-term pregnancy Risk of stillbirth- 37 weeks 1/3000 - 42 weeks 3/3000 - 42 weeks 3/3000 - 43 weeks 6/3000 - 43 weeks 6/3000 In a meta-analysis, routine induction at 41 weeks reduced perinatal death without increase in C/S rate Most guidelines recommend routine induction after 41 weeks Beyond 42 weeks, assess fetal well being with NST and AFV Sweeping membranes reduces need for labor induction