F UNDAMENTALS OF O BSTETRICS Christine Pecci, MD Associate Clinical - PowerPoint PPT Presentation

F UNDAMENTALS OF O BSTETRICS Christine Pecci, MD Associate Clinical Professor UCSF Department of Family and Community Medicine March 2017

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O BJECTIVES  Describe the group prenatal care model  Review criteria for ultrasound vs LMP dating  Review management of women at risk for preterm delivery  Describe guidelines for diagnosis, treatment and management of preeclampsia, gestational diabetes and thyroid disease in pregnancy  List infections in pregnancy and how to manage or prevent these from occurring

P RENATAL CARE MODELS : DO WE KNOW WHAT ’ S BEST ?  Traditional care-ACOG  Q 4 wk visits until 28 weeks  Q 2 wk visits until 36 weeks  Q 1 wk visits until delivery  Traditional care- ICSI  8-11 visits total  6-8 wks, 10-12 wks, 16-18 wks, 22 wks, 28 wks, 32 wks, 36 wks, 38-41 wks  Group Prenatal Care  Group of 5-12 patients x 2 hours q 2-4 wks

G ROUP OR TRADITIONAL PRENATAL CARE ?  Similar rates of PTD, NICU admission and breastfeeding initiation rates  African American women with significantly lower PTD rate* but not among Latina  Decreased rate of LBW overall**  No harm in doing group care and likely benefit in certain groups Carter et al OB GYN Sept 2016

 Tanya is a 23 yo G1P0 who presents for early pregnancy care. EGA 10 1/7 wks by a sure LMP  She had a visit to ED for nausea and vomiting  Given 1 liter NS  Electrolytes were normal  TSH 0.1

N AUSEA AND VOMITING IN PREGNANCY  Nausea in 50-80%  Vomiting/retching 50%  Hyperemesis gravidarum 0.3-3%  Persistent vomiting  Weight loss  Ketonuria  Usually electrolyte, thyroid, liver abnormalities  Lower rate of miscarriage ACOG Practice Bulletin April 2015

T REATMENT OF N / V IN PREGNANCY  Multivitamin x 3 months before conception  Ginger may decrease nausea  Acupuncture/acupressure- no difference in RCTs  First line treatment pyridoxine +/- doxylamine  Metoclopromide, ondansetron second line  Limited safety data, but overall risk low  Oral corticosteroids used as last resort– avoid 1 st trimester ACOG Practice Bulletin April 2015

N ORMAL T HYROID FUNCTION AND PREGNANCY  Hcg stimulates TSH receptor, increasing thyroid production and decreasing TSH  Total thyroid hormone levels increase due to elevated thyroid-binding globulin (TBG)  Free T4 unchanged ( direct assays ok but many labs use automated assays which can be inaccurate )  TSH is a reliable indicator of maternal thyroid status (American Thyroid Association)  First trimester 0.1-2.5 mIU/L  Second trimester 0.2-3.0 mIU/L  Third trimester 0.3-3.0 mIU/L

H YPERTHYROIDISM IN PREGNANCY  Avoid meds in 1 st trimester  If medication needed, use PTU  risk of liver failure  Risk face and neck cysts  Consider changing methimazole after 16 wks (aplasia cutis) other congenital malformations  Smallest possible dose as medications cross placenta and can be more potent for fetal thyroid  Target: at or just above upper range of normal  Moniter TSH/T4 every 4 wks if on medication

H YPOTHYROIDISM  Case control trials showed hypothyroidism associated with low IQ in the fetus  RCTs do NOT confirm that treatment of subclinical hypothyroidism improves neurocognitive outcomes  Both initiated Rx after first trimester  Universal screening for thyroid disease in pregnancy is not indicated*  Increased pregnancy loss with elevated TSH, especially if TPO ab elevated  Effectiveness of Rx not yet proven  Maybe need to screen 4-7 wks? *ACOG, Endocrine Society, American Association of Clinical Endocrinologists

R ECOMMENDATIONS  Treat if TSH >10  TSH>2.5 check TPO Ab status  ?treat if TPO Ab+ and TSH >2.5  Don’t treat if TPO neg and TSH > upper nl <10  If treating  Target lower half of preg specific range or <2.5  Measure q4 wks in pregnancy then at least once near 30 wks American Thyroid Association 2017

S UPPLEMENTATION AND PREGNANCY  50-85% need increase in thyroid replacement  Preconception treat to <2.5  Should increase dose by 25-30% ASAP post conception (can give two extra pills/wk)  Postpartum following delivery go back to pre- pregnancy dose and recheck in 6 wks  If Rx started in pregnancy with nl TSH reasonable to stop and recheck in 6 wks

LMP VS . US DATING  Tanya also had an US done in the ED  Crown-rump length = 9 2/7 weeks  LMP 10 1/7 wks  6 days different than EDD based on LMP  Should you change her dating based on 1 st trimester US?

D ATING Gestational Age Discrepancy for re-dating w US date < 9 weeks > 5 days (CRL) 9 weeks to < 14 weeks > 7 days (CRL) 14 weeks to < 16 weeks > 7 days (BPD, HC, AC, FL) 16 weeks to < 22 weeks > 10 days 22 weeks to < 28 weeks > 14 days 28 weeks and beyond > 21 days Single uniform standard based on expert opinion (ACOG, AIUM, SMFM) EDD=280 days after first day LMP Half of women accurately remember LMP 40% adjustment in 1 st trimester; 10% adjustment 2 nd trimester Use earliest US ACOG Committee Opinion Oct 2014

W ILL MY BABY BE NORMAL ?  She has been reading about a new test for making sure the baby is normal. She wants to know if you can order this test. Will having a normal test guarantee that this baby will be okay?

Characteristics of screening tests:T21 Dashe, Jodi MD Obstet Gyn 2016

Options for screening First Trimester Second Trimester hcg + PAPP-A hcg + AFP + estradiol + inhibin 11-14 wks 15-22 wks Can be combined w NT Anatomy scan AFP in 2nd trimester for NTD Includes AFP • 1 st trimester screening gives the patient early results • 2nd trimester screening good for late entry to care • DON’T do both independently • CAN do combined (7 serum markers + NT)

C OMBINED 1 ST AND 2 ND TRIMESTER SCREENING  Sequential testing Stepwise  high risk offered diagnostic testing after 1 st trimester  Others get results after second trimester Contingent  highest risk offered diagnostic testing after 1 st tri  lowest risk reassured- no further testing  Others get results after 2 nd trimester  Integrated testing

C ELL - FREE DNA  Circulating DNA fragments placental in origin from apoptotic trophoblasts  Can be done anytime after 9-10 wks gestation  Available in 7-10 days  Best for trisomy 21 and 18 but also screens for trisomy 13 and sex chromosome aneuploidies  Gender  Can be used as primary or secondary screening AJOG June 2016 SMFM Consult Series

Dashe, Jodi MD Obstet Gyn 2016

I’ M SO NERVOUS …  Tanya is worried specifically about preeclampsia because her sister had it and needed to be induced a few weeks before her due date.  “Is there anything that you can give me so that I don’t get this disease too?”

P REECLAMPSIA : Y OU WILL SEE IT !  Incidence 2-8%  Has increased by 25% in last two decades  More likely in patients with hypertension  Unrecognized has serious health consequences for mom and baby  Risk factor for future CV and metabolic disease Task Force for Hypertension in Pregnancy, 2013

I NITIATE ASA 12-28 WKS FOR HIGH RISK  History of pre-eclampsia, esp if adverse outcome  Multi-fetal gestation  Chronic hypertension  Diabetes type 1 or 2  Renal disease  Autoimmune disease (SLE, APS)  Patient with history of preeclampsia <34 wks  Prevalence 40%  NNT 1:20 Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia: Updated Recommendations July 11 , 2016

C ATEGORIES  Preeclampsia-eclampsia  With or without severe features  Chronic hypertension  Gestational hypertension- hypertension without proteinuria after 20 week  Chronic hypertension with superimposed preeclampsia Task Force for Hypertension in Pregnancy, 2013

P ROTEINURIA  >300 mg in 24 hrs  Spot urine:creatinine ratio > 0.3  Dipstick 1+  Proteinuria is classically part of the syndrome  But NOT required to make diagnosis of preeclampsia

D IAGNOSIS  Elevated BP  >140/90 on two occasions 4 hours apart  Proteinuria or “severe features”  >160/110  Plts <100K  LFTs twice normal  Persistent RUQ pain or epigastric pain  Creatinine >1.1 or double  Pulmonary edema  New onset cerebral or visual disturbance

W HEN TO DELIVER ?  Chronic hypertension  Deliver after 38 0/7 wks  Gestational hypertension:  Deliver at 37 0/7 weeks  weekly dip for proteinuria + BP check (can be at home)  NST q week

W HEN TO DELIVER ?  Preeclampsia without severe features:  Deliver at 37 0/7 weeks  2x week BP, once a week labs  2x week NST  Preeclampsia with severe features  Deliver at 34 0/7 weeks  Monitor in hospital  Severe uncontrolled htn, eclampsia, pulm edema, abruption, DIC, NRFHR, IUFD  Immediate delivery after initial stabilization

I NTRAPARTUM I NTERVENTIONS  Mg with severe preeclampsia only  Anti hypertensive meds only for > 160/110  Administer steroids prior to delivery

P OSTPARTUM FOLLOW - UP  Check BP 72 hours post delivery and 7-10 days postpartum  Treat for >150/100 on two occasions 4-6 hrs apart  Preconception- glycemic control, weight loss  ALL patients should receive education on warning signs