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

F UNDAMENTALS OF O BSTETRICS Christine Pecci, MD UCSF Department of Family and Community Medicine March 2016

 No disclosures

O BJECTIVES  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 or 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 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

 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

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?

A NEUPLOIDY S CREENING  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)

N ON - INVASIVE P RENATAL T ESTING (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 offer invasive testing  False positive 0.5%, 98-99% Trisomy 21 detected

H OW 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

E XERCISE IN P REGNANCY  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

N UTRITION IN P REGNANCY 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

D ISEASES IN P REGNANCY

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

W HO 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%)

T ASK F ORCE FOR H YPERTENSION IN P REGNANCY , 2013  17 experts (OB, MFM, htn, nephrology, anesthesia, physiology, patient advocacy)  Changes in terminology  Changes in management

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

M ANAGEMENT  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

M ANAGEMENT  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 (low/qual)  Anti hypertensive meds only for > 160/110 (mod/strong)  Administer steroids prior to delivery (high/ strong)

P OSTPARTUM 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

D IABETES IN P REGNANCY  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

G ESTATIONAL D IABETES  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

D IAGNOSIS  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

T REATMENT  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

M ODE 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

P OSTPARTUM 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

I NFECTIONS IN P REGNANCY

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-G IVE 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