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

FUNDAMENTALS OF OBSTETRICS

Christine Pecci, MD Associate Clinical Professor UCSF Department of Family and Community Medicine March 2017

 No disclosures

OBJECTIVES

 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

• r prevent these from occurring

PRENATAL 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

GROUP 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

NAUSEA 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

TREATMENT 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 1st

trimester

ACOG Practice Bulletin April 2015

NORMAL THYROID 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

HYPERTHYROIDISM IN PREGNANCY

 Avoid meds in 1st 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

HYPOTHYROIDISM

 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

RECOMMENDATIONS

 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

SUPPLEMENTATION 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 1st

trimester US?

DATING

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 ACOG Committee Opinion Oct 2014 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 1st trimester; 10% adjustment 2nd trimester Use earliest US

WILL 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

• kay?

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

• 1st 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)

COMBINED 1ST AND 2ND TRIMESTER

SCREENING

 Sequential testing

Stepwise

 high risk offered diagnostic testing after 1st trimester  Others get results after second trimester

Contingent

 highest risk offered diagnostic testing after 1st tri  lowest risk reassured- no further testing  Others get results after 2nd trimester  Integrated testing

CELL-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?”

PREECLAMPSIA: YOU 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

INITIATE 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

CATEGORIES

 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

PROTEINURIA

 >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

DIAGNOSIS

 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

WHEN 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

WHEN 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

INTRAPARTUM INTERVENTIONS

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

POSTPARTUM 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

ROUTINE US 18-22 WKS

 Confirms dating if not already done  Anatomy scan  ? Cervical length  Universal screening not indicated

SCREEN FOR GDM AT 24-28 WKS

 Overall incidence of

DM in pregnancy 6%

 90% of these are GDM  Early screening- if

prior GDM, known impaired fasting glucose, BMI >30

GESTATIONAL DIABETES

 HAPO trials show continuous relationship-

neonatal hypoglycemia, macrosomia

 Increased hyperbilirubinemia, operative delivery,

shoulder dystocia

 2010 International Association of Diabetes and

Pregnancy Study Group (endorsed by ADA) (92, 180, 153)

 No data regarding therapeutic intervention

ACOG Practice Bulletin Aug 2013

DIAGNOSIS OF GDM

 2013 NICHD recommends 2 step test (50 gm

then 100 gm)

 Consider prevalence of diabetes  Consider resources  One hour glucola: range 135-140

fasting 1 hr 2hr 3hr NDDG* 105 190 165 155 CC** 95 185 165 140 *National Diabetes Data Group **Carpenter Coustan

MANAGEMENT AND TREATMENT

 QID fingersticks  Goal <140 on 1 hr and < 120 2 hr  Carbs 33-40% of diet; Protein 20%; fat 40%  Moderate exercise  If fasting consistently >95, consider insulin  Insulin does not cross the placenta  Glyburide and metformin  not approved but being used  Glyburide crosses placenta but no measurable levels

in cord blood

WHEN TO DELIVER?

 Induce at 39 weeks if pre-gestational or

gestational DM on meds

 For well controlled GDM without meds, unclear

whether induction is indicated.

MODE OF DELIVERY WITH DIABETES

 Prevention of a single permanent brachial plexus

palsy

 Cesarean delivery for 4500 gm NNT 588  Cesarean delivery for 4000 gm NNT 962

POSTPARTUM FOLLOW-UP

 15-50% with GDM develop DM 20+ years later  Varies by ethnicity (60% Latina within 5 years)  Fasting or 2 hr GTT 4-12 wk postpartum  IGT picked up by 2 hr  Repeat testing q 3 years if normal

INFECTIONS IN PREGNANCY

HSV

 Genital herpes affects 20% women in US?  Incidence of new infection in preg 2%  Women with recurrent HSV-75% can expect

episode during preg, 14% at delivery

 80% of infected infants born to women with no

reported history

 20% neonatal survivors have long-term

neurosequealae

HSV-GIVE PROPHYLAXIS AT TERM

 Primary infection transmission - 30-60% at delivery  Recurrent infection transmission 3% at delivery; no

lesions 2/10,000

 Acyclovir, famcyclovir, valcyclovir all class B, most

data on acyclovir

 Routine screening not recommended  Genital Sx or lesions- c/s decreases transmission from

7.2% to 1.2% even after ROM

Acyclovir 400 mg TID @ 36

weeks til delivery

HIV

 Opt out screening for ALL women  Low threshold for repeating in third trimester; offer

testing on L&D

 Early viral suppression is of upmost importance  Elective cesarean if VL >1000 near delivery  Intrapartum AZT unless consistent VL <1000  Neonatal AZT prophylaxis required for 4-6 weeks  add if NVP high risk  Consider offering presumptive treatment (AZT+NVP+3TC)  No breastfeeding (developed countries)  Clinician Consultation Center Perinatal hotline 24/7  http://nccc.ucsf.edu/

GBS

 Screen all women at 35-37 wks, unless  Previous child with early onset GBS disease  GBS bacteruria in index pregnancy  Treat with intrapartum IV penicillin first line  Ask for sensitivities if has pcn anaphylaxis to see if

can give Clinda/erythro

 Cefazolin if no anaphylaxis reaction to penicillin  Vanco reserved for those with anaphylaxis or those

without sensitivities

 Adequate treatment >4 hours pcn or cefazolin

ZIKA VIRUS

Transmitted by Aedes species of mosquitos

• also transmit dengue fever, chikunguya viruses

Incubation period 3-12 days Symptoms 2 or more of following

• fever, rash, arthralgia or conjunctivitis

Can be transmitted in all trimesters Sexual transmission has been documented via semen

Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory (as of February 1, 2017)

ZIKA VIRUS IN PRE/POST CONCEPTION

 Pre-conception  women: wait 8 wks after sx start or last exposure  Men: wait 6 months  If pregnant: Avoid travel to active Zika virus

areas or take measures to avoid mosquito bites

 Use condom if partner is travelling to Zika areas  For those living or travelling frequently to Zika

areas, do testing

 Ask about travel to endemic countries  Protected from future infections

ZIKA TESTING

 Test those with clinical illnesses (2 or more sx)

during or within 2 weeks of travel

 RNA NAT and Zika Ig M  Offer RNA NAT to pregnant women 2-12 weeks

after travel if they are Zika IgM

 Testing done by CDC and state health depts

ZIKA AND FETAL CONCERNS

 Microcephaly (at birth or postnatally)  Congenital Zika Syndrome  Severe microcephaly where skull partially collapsed  Specific pattern of brain damage and decreased brain

tissue

 Damage to back of eye  Joints with limited ROM (club foot)  Hypertonia

ZIKA AND FETAL MONITORING

 Get ultrasound 3-4 weeks within exposure  Serial scans q 3-4 wks  Offer amnio in documented infection  unknown how long positive or ability of test to

determine fetal injury

 Send fetal tissue/placenta  Ok to breastfeed

ZIKA RESOURCES

 https://www.cdc.gov/zika/hc-providers/pregnant-

woman.html

 Call 770-488-7100 and ask for the Zika

Pregnancy Hotline or email ZIKAMCH@cdc.gov

56

RUBELLA

 Do not give during pregnancy and avoid pregnancy x

28 days

 Not an indication for termination  If lab evidence of immunity, no need to repeat  If neg or equivocal titer after 1-2 doses, give third dose

and stop checking titers

 Ok for children of pregnant women to get  May give with Rhogam, check titer in 3 months

MMWR June 2013

VARICELLA

 Lab evidence of immunity or

disease

 Birth in US before 1980 is not

sufficient for pregnant women

 Diagnosis or verification of

history of varicella or zoster by health care provider

 Should have link to a typical

case or lab confirmation if testing done during acute infection

 Tanya declined the Tdap and flu shot pregnancy

because she was afraid of it hurting the baby.

 Postpartum she is willing to accept these two

immunizations if you still recommend them. She got the flu shot last season and got a Tdap after her last pregnancy in 2011.

 Which immunizations would you give her?

TDAP IN EACH PREGNANCY

 Tdap is indicated in EVERY pregnancy 27-36

wks EGA for transmission of antibodies to fetus

 Once baby is out, indication for Tdap is based on

maternal indications; she is up to date

 Flu shot is indicated

SUMMARY

 Establish accurate dating  Provide primary care  Immunizations, healthy lifestyles  Preconception (thyroid adjustment, zika travel)  Watch for pregnancy related diseases  Translates to risk of these diseases later in life  Some interventions indicated early in pregnancy  We have interventions to prevent perinatal

transmission of disease