F UNDAMENTALS OF O BSTETRICS Christine Pecci, MD UCSF Department of - - PowerPoint PPT Presentation

FUNDAMENTALS OF OBSTETRICS

Christine Pecci, MD UCSF Department of Family and Community Medicine March 2016

 No disclosures

OBJECTIVES

 Review criteria for ultrasound vs LMP dating  List healthy practices in pregnancy  Describe guidelines for diagnosis, treatment and

management of preeclampsia and diabetes

 List infections in pregnancy and how to manage

• r prevent these from occurring

 Tanya is a 23 yo G1P0 who presents for early

pregnancy care. This is a planned pregnancy. She is 10 1/7 wks by a sure LMP

 She had some bleeding yesterday and went to ED

where she had an US that puts her at 9 2/7 weeks today (6 days different than EDD based on LMP)

 Reports regular menses q month  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

 We confirm that Tanya has a “sure” LMP  We will calculate her EDD based on her LMP  US discrepancy is 6 days but between 9-14 weeks

we would use the US based EDD only if it differs by >7 days

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?

ANEUPLOIDY SCREENING

 First trimester 10-15 weeks  Serum testing (free bhg + PAPP-A)  Ultrasound (NT)  Second trimester screening 15-20 weeks  Serum testing (AFP, inhibin, bhcg, estriol)  Ultrasound (fetal survey)  Step-wise vs integrated testing  NOT diagnostic (need CVS or Amniocentesis)

NON-INVASIVE PRENATAL TESTING (NIPT)

 Cell free fetal DNA  Comes from placental cells and clears from

maternal system in hours

 Tests for Trisomy 18, 21, 13  Can be checked 10 – 22 weeks gestation  Only for high risk patients  Age >35, abn US, history of trisomy, parent with

balanced translocation

 If positive result, refer to genetic counseling and

• ffer invasive testing

 False positive 0.5%, 98-99% Trisomy 21 detected

HOW DO I STAY HEALTHY DURING

PREGNANCY?

IOM WEIGHT GAIN GUIDELINES

Pre Preg BMI BMI Total Weight Gain Underweight <18.5 28-40 Normal 18.5-24.9 25-35 Overweight 25.0-29.9 15-25 Obese >30 11-20 Institute of Medicine 2009

EXERCISE IN PREGNANCY

 Goal: 30 minutes most days of the week  If sedentary, start out slowly ie 5 min daily  Avoid contact sports or high risk of falling  Avoid sports that involve balance changes  No scuba diving  Keep off back, drink lots of water  Listen to your body

NUTRITION IN PREGNANCY

Folic Acid: 600 mcg folic acid Iron: 27 mg Calcium: 1000-1300 mg Vit D: 600 IU

ACOG Sept 2013

I love hot dogs!

 Pregnant women more likely to be affected  Avoid refrigerated smoked seafood, pate,

unpasteurized milk/cheese

 Deli meats/hot dogs need to be steaming hot

I LOVE MY CAT!

 Ingestion of raw/undercooked meat, unwashed

fruits/vegetables, soil or litter contaminated with cat feces

 Wash hands  Have someone else clean cat litter  Use gloves  Change litter box daily  Do not feed raw meat to cats

I’M GLAD I DON’T LIKE FISH!

 Fish is good for you and provides necessary

nutrients for growing fetus

 Should eat on average two meals a week  8-12 oz of fish/shellfish a week  Avoid swordfish, tilefish, king mackerel, shark

DISEASES IN PREGNANCY

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

WHO SHOULD TAKE ASA?

 Initiate ASA 81 mg in late first trimester  History of preeclampsia < 34 0/7 weeks  Preeclampsia in more than one pregnancy  Patient with history of preeclampsia <34 wks  Prevalence 40%  NNT 1:20 (moderate Q; qualified SOR)  NNT 1:500 low risk (prev 2%)  NNT 1:50 high risk (prev 20%)

TASK FORCE FOR HYPERTENSION

IN PREGNANCY, 2013

 17 experts (OB, MFM, htn, nephrology,

anesthesia, physiology, patient advocacy)

 Changes in terminology  Changes in management

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

MANAGEMENT

 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

MANAGEMENT

 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 (low/qual)  Anti hypertensive meds only for > 160/110

(mod/strong)

 Administer steroids prior to delivery (high/

strong)

POSTPARTUM FOLLOW-UP

 Incidence unknown  ALL patient should receive education on warning

signs

 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

DIABETES IN PREGNANCY

 Overall incidence of diabetes in pregnancy 6%  90% of these are GDM  HAPO trials show continuous relationship-

neonatal hypoglycemia, macrosomia

 Increased hyperbilirubinemia, operative delivery,

shoulder dystocia

ACOG Practice Bulletin Aug 2013

GESTATIONAL DIABETES

 Screen at 24-28 wks  Early screening- if prior GDM, known impaired

fasting glucose, BMI >30

 2010 International Association of Diabetes and

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

 No data regarding therapeutic intervention

DIAGNOSIS

 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

TREATMENT

 QID fingersticks  ADA and ACOG 140 on 3 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

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 6-12 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

ZIKA VIRUS

 Prior to 2007, only sporadic cases in Africa  2007 first outbreak in Federated States of Micronesia

(Yap Island)

 2013-2014 French Polynesia  First outbreak in Americas- May 2015  February 1, 2016, the World Health Organization

declared a Public Health Emergency of International Concern (PHEIC) because of clusters of microcephaly and other neurological disorders in some areas affected by Zika

 February 8, 2016, President Obama announced a

request for $1.8 billion in emergency funds for several agencies to accelerate research into a vaccine and educate populations at risk for disease.

Countries with reported local transmission

• As of Jan 23, 2016 (CDC slide set)

ZIKA VIRUS

 Consider postponing travel if pregnant  Ask about travel to endemic countries  Test those with clinical illnesses (2 or more sx)

during or within 2 weeks of travel

 Zika virus RT PCR and Zika Ig M  Offer testing to pregnant women 2-12 weeks after

travel with Zika IgM

 Testing done by CDC and state health depts  http://www.cdc.gov/zika/

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

49

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

 Mary is 36 yo G2P2 delivered 2 days ago via

cesarean delivery. She had declined the Tdap and flu shot pregnancy because she was afraid of it hurting the baby. Now 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  Watch for pregnancy related diseases  Translates to risk of these diseases later in life  We have interventions to prevent perinatal

transmission of disease