Associate Professor UNM Department of Family and Community Medicine Maternal and Child Health Resident SchoolSeptember 6 2017 Goal Update your knowledge of standard prenatal care recommendations ID: 816586
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Slide1
Prenatal Care Refresher
Sarah Gopman, MD
Associate Professor
UNM Department of Family and Community Medicine
Maternal and Child Health Resident School—September 6, 2017
Slide2Goal: Update your knowledge of standard prenatal care recommendations
Explain the recommended approach for establishing the best
estimated due date
Succinctly
describe
for patients the options
for
genetic screening and testing
in
pregnancy
Discuss
common
historical health issues
which have relevance to the current
pregnancy
Describe common
prenatal laboratory abnormalities
and their
management
List important
counseling and education topics
in prenatal care
Discuss frequently encountered indications for
fetal surveillance
Describe an approach to counseling women regarding
trial of labor after cesarean
section
Slide3Why is it important to establish the best due date?
Pregnancy management decisions are almost all dependent on gestational age
Timing of genetic screening and other testing
Decisions about steroids and
tocolysis
Timing of deliveries for medical indications
Decisions are more complicated with poor dating
Increasingly we recognize potential harms from “late preterm” deliveries (34 0/7 to 36 6/7
wks
) so being “off” by even 1-2
wks
can make a difference
Slide4Early First
Trimester
US
Slide5Later First
Trimester US
Slide6Once US is done, how do I choose the best estimated date of delivery (EDD)?
Is the LMP certain? Requires
all
the following:
Recorded at the time or clearly remembered
Has a predictable, regular menses
Normal amount of flow and duration
No hormonal contraception for 3 months prior
If LMP is uncertain, just use the US EDD
Slide7Table 1.
Guidelines for
Re-dating
Based on Ultrasonography
Gestational
Age
Range
Method of
Measurement
Discrepancy
Between Ultrasound
Dating and LMP
Dating That
Supports Re-dating≤13 6/7 wk: ≤ 8 6/7 wk 9 0/7 wk to 13 6/7 wkCRL More than 5 dMore than 7 d14 0/7 wk to 15 6/7 wkBPD, HC, AC, FLMore than 7 d16 0/7 wk to 21 6/7 wkBPD, HC, AC, FLMore than 10 d22 0/7 wk to 27 6/7 wkBPD, HC, AC, FLMore than 14 d†28 0/7 wk and beyondBPD, HC, AC, FLMore than 21 dAbbreviations: AC, abdominal circumference; BPD, biparietal diameter; CRL, crown–rump length; FL, femur length; HC, head circumference; LMP, last menstrual period.†Because of the risk of re-dating a small fetus that may be growth restricted, management decisions based on third-trimester ultrasonography alone are especially problematic and need to be guided by careful consideration of the entire clinical picture and close surveillance.
Adapted from ACOG Committee Opinion 611, October 2014 (reaffirmed 2016)
Slide8Are there any caveats to using US to determine EDD?
Use earliest US that has embryo w/ fetal heart motion (i.e. a crown-rump length, not a gestational sac measurement)
Using US at > 20
wks
GA to determine EDD is difficult
IUGR
Macrosomia
C
onstitutionally small or large fetuses
**Consultation is recommended**
Avoid use of “unofficial” US for dating
P
regnancy crisis (anti-abortion) counseling services
For-profit “gender” scans
Slide9Who should be offered genetic counseling, screening, and testing in pregnancy?
Easy answer: EVERYONE should be
offered
screening/testing!
Some are at increased risk of carrying fetuses w/ genetic abnormalities
AMA
Twin gestation
Prior affected child
Some are at increased risk of carrying fetuses with “exposure-related” anomalies
Alcohol
Certain
rx’d
drugs: ACE-I, anti-
sz meds, coumadin, etc.Uncontrolled pre-gestational diabetes
Slide10What is the difference between genetic screening
and
testing
?
Screening
N
on-invasive
N
o risk to the pregnancy
G
ives relative risk, e.g. 1:5000 risk of DS
Testing
Invasive (except cell free fetal DNA test, which has a status somewhere between screening and testing…)
Carries some risk of miscarriage or pregnancy lossGives definitive answer (diagnostic), e.g. baby has 47 chromosomes (X,Y, 21 X 3)
Slide11What are the diagnostic
testing options?
Historically, amniocentesis has been offered
>
35 at time of delivery
“Positive”
screening test
History of prior affected pregnancy
Performed at 15-20
weeks
Collects amniotic fluid, which includes fetal cells
Risk of pregnancy loss after
amnio
= 1:200 (hence triple screen “positive” at 1:270)
Slide12What are the diagnostic
testing options?
Chorionic villous sampling indications similar to
amnio
Performed at 10-13 weeks
Transcervical
or
transabdominal
approach to collect placental tissue
Pregnancy loss rate ~1:100
Only
amnio
and CVS are diagnostic (i.e. retrieve chromosomal material
)All patients should be aware of the option for diagnostic testing, though most will decline itPatients who know they want diagnostic testing should not have a screening test
Slide13How do the triple
and
quadruple
screens compare for second trimester evaluation?
Standard mid-trimester
screening tool in the
U.S
. for 15 years
was the “multiple marker” or triple screen
S
erum AFP,
hCG
, and
uE3Performed between 15 and 22 weeks1:270 risk = “positive” result (73% sensitivity; 9% false positive rate)Adding inhibin-A (quadruple test) gives 81% sensitivity and 5% false positive rate
Slide14What about the first trimester screen?
Performed
between
11 5/7 and
and
13 6/7 weeks
Advantages
and
disadvantages
early
reassurance or opportunity for
diagnosis
no
AFP, therefore does not eval NTD risk Free B-hCG and PAPP-A (67% sensitivity, 5% false positive rate when serum testing used alone)Nuchal translucency is second component of the first trimester screen Ultrasound measurement of the thickness of the soft tissues at the back of the fetal neckNuchal translucency combined with serum markers gives sensitivity 79% and false positive rate 5%
Slide15Nuchal Translucency
AIUM Website
Slide16Nuchal Translucency
Souka
et al. Ultrasound
Obstet
Gynecol
2001
Slide17What else can first trimester screening assess besides risk of chromosome abnormality?
Abnormal
first trimester serum markers
or
increased
NT
also increases risk
of
Spontaneous loss before 24
wks
Fetal demise
Low birth weight
Preterm birth
Slide18What is the integrated screen?
Attempt to combine benefits of 1st and 2nd trimester screening
1st trimester screen performed, but results not disclosed
2nd trimester screen (quad test) obtained, total result calculated and disclosed
Sensitivity 85% with false positive rate 1.2
%
Sensitivity 94-96% with screen-positive rate 5
%
Disadvantage = no opportunity to consider CVS if first trimester screening shows high risk
Slide19What
about a
stepwise
sequential
testing
model?
1
st
tri screen performed
and results given
If “positive,” genetic counseling and cell free fetal DNA vs. chorionic villus sampling offeredIf “negative,” quad test performed at 15 wksUltimate result integrates findings of 1st and 2nd trimester into a final risk assessmentSensitivity is 95%, with false positive rate 4.9%(At same 95% sensitivity, integrated screen gives false positive rate 4.0%, so only slightly better than stepwise)
Slide20What about
independent
sequential
screening?
Quad
test
interpreted independently of
1
st
trimester
screen
For sensitivity of 94%,
false positive rate is 11-17%False positive rate is essentially additive for the two testsThis should not be done!
Slide21How about a contingent model?
Another approach to sequential testing
First trimester screen generates one of three possible results
Cutoffs vary among institutions. One example:
“
high
”
risk is >
1:65
“
intermediate
”
risk is 1:65 to 1:1300“low” risk is < 1:1300High risk offered CVS or cell free fetal DNA testLow risk no further testingIntermediate risk offered second trimester testIf both performed, both tests are used to calculate a final riskUNM Prenatal Diagnosis and Genetic Testing is currently offering the sequential screen (not contingency model)
Slide22DS Detection at 5% Positive Screen Rate
(ACOG Practice Bulletin No. 77)
Nuchal Translucency (NT)
64-70
First Trimester Screen
82-87
Triple Screen
69
Quadruple Screen
81
Integrated Screen
94-96
Serum
Integrated Screen (no NT) 85-88Stepwise Sequential Screen 95Contingent Sequential 88-94Screening TestDetection Rate (%)
Slide23What is the cell free fetal DNA test?
3-13% of free DNA in the maternal serum is derived from fetus
DNA seems to come from the placenta
Disappears from maternal circulation by a few hours after delivery
Can be used as a screening test in high risk pregnancies, or as a “next step” following a high risk screening test
For an abnormal result, confirmatory
CVS/
amnio
must be
done prior
to
intervention
Slide24What is the cell free fetal DNA test?
Indications for Considering the Use of Cell Free Fetal DNA (per December 2012 ACOG Committee Opinion No. 545)
Maternal age
>
35 at delivery
U/S markers of aneuploidy seen
Prior trisomy pregnancy
“Positive” screening test for aneuploidy: first tri,
sequential
,
second tri
Parental balanced
Robertsonian
translocation with increased risk of fetal trisomy 13 or 21
Slide25What conclusions can be made in comparing
s
creening tests?
First trimester, second trimester,
sequential,
and integrated screening are all acceptable
Choice will depend upon gestational age at
presentation, patient preference, and local availability
Individual patient might accept first trimester screening, but decline full integrated/sequential screen due to unwillingness to terminate a second trimester pregnancy
Quad test more
expensive than triple screen,
therefore patients
may
not have access to this test at certain sites (First Choice?, First Nations?, etc.)UNM patients who are referred to Prenatal Diagnosis and Genetics clinic for screening in the first trimester are getting stepwise sequential screens, unless they qualify for cell free fetal DNA
Slide26How can I explain all this to a patient?
Would you be interested in testing that could help you find out if your baby has a genetic abnormality, for example Down Syndrome?
Would you want a definite answer (“yes/no”) and be willing to accept some risk of miscarriage, or prefer no risk to the pregnancy and accept just an estimate of risk (“high/low”)?
Availability of the free fetal DNA test changes the conversation somewhat for women with increased risk of chromosome abnormalities.
Slide27What are the reasons patients decide in favor of and against screening/testing?
In Favor
Would terminate an affected pregnancy
Would help prepare for an affected baby
Would change plans for mode of delivery
Would feel less anxious during the pregnancy if “normal” result
Against
Would not change plans for the pregnancy
“Abnormal” result would decrease enjoyment of pregnancy
Slide28How is ultrasound used to
detect aneuploidy
and
other anomalies?
Ultrasonographic
“
anatomic survey
”
at 18-20 weeks = important tool to dx NTD, other structural abnormalities
May reveal markers for chromosome abnormalities
Major cardiac anomaly
Pyelectasis
Shortened femur or humerusEchogenic bowelThickened nuchal foldEchogenic intracardiac focusHypoplastic fifth digitSandal gap toe
Slide29U
ltrasound Finding: Echogenic
B
owel
ISUOG Educational Committee; Gianluigi Pilu, Kypros Nicolaides,
Renato Ximenes, Philippe Jeanty
Slide30Ultrasound Finding:
E
chogenic
C
ardiac
F
ocus
ISUOG Educational Committee; Gianluigi Pilu, Kypros Nicolaides,
Renato Ximenes, Philippe Jeanty
Slide31Ultrasound
Finding: Choroid Plexus Cyst
ISUOG Educational Committee; Gianluigi Pilu, Kypros Nicolaides,
Renato Ximenes, Philippe Jeanty
Slide32Ultrasound Screening
for Neural
Tube Defects
Spina
Bifida
Normal
Meningomyelocele
Slide33What can we say about risk based on
ultrasound findings?
Age-related risk of DS can be multiplied by likelihood ratio of a given
US
marker
Unreliability of obtaining markers makes this not practical in a low-risk
population
Absence of all markers decreases DS risk by 50-60%
Many anomalies are missed by
US
50-75% detection rate for DS in second trimester in
high-risk
population
For 100% detection rate, false positive rate increases to 21.9%
Slide34What are some common pre-existing health issues that affect pregnancy?
Hypothyroidism
Check TSH at diagnosis of pregnancy and q4-6 weeks
Some increase levothyroxine by 30% as soon as pregnancy diagnosed
Goal TSH is
<
2.5 (< 3.0 in 2
nd
and 3
rd
trimesters)
Ask about prior
hx
of thyroid ablation (i.e. Graves disease)Most patients can return to pre-pregnancy levothyroxine dose after delivery and recheck TSH at 6 weeks postpartum
Slide35What are some common pre-existing health issues that affect pregnancy?
Obesity
Screen for DM at diagnosis of pregnancy:
HgbA1C
>
6.5 = GDM (probably DM2)
HgbA1C 5.8 – 6.4 and fasting
>
93 = GDM
HgbA1C 5.8 – 6.4 and fasting < 93
rescreen at 24-28
wks
GA
If initial HgbA1C < 5.7, rescreen with 1hGTT at 24-28 wks (abnormal = 130) Recommend less weight gain (use Institute of Medicine Guidelines)Fundal heights often inaccurate and may require US for fetal growth evaluationEncourage exercise, especially after meals
Slide36Slide37What are some common pre-existing health issues that affect pregnancy?
Sexually transmitted infections
Chlamydia
O
ften asymptomatic
C
an cause spontaneous abortion and preterm delivery
T
x
w/ azithromycin 1g
po
X 1
Partner
tx is importantTOC at 4-6 weeks after txHSVNeonatal risk is highest w/ primary infection near time of deliveryTx w/ acyclovir for outbreaks prnProphylaxis at 34-36 wks GA w/ acyclovir 400mg po tid until deliveryc/s if active lesions at the time of labor (or primary infection in the third trimester)
Slide38What are some common pre-existing health issues that affect pregnancy?
Sexually transmitted infections
Trichomoniasis
Generally no known risk to
pregnancy (increase PPROM risk?)
Treat if symptomatic
Treatment can increase risk of PPROM
Bacterial
Vaginosis
Not an STI but often picked up on a pap or wet prep
Treat if symptomatic or if other risk factors for preterm
delivery
Tx
needs to be oral to decrease PTD risk: metronidazole 500mg po bid X 7 daysNo convincing evidence of teratogenicity but some prefer to avoid tx in the first trimester
Slide39What are some common pre-existing health issues that affect pregnancy?
Frequent urinary tract infections
Can be asymptomatic in pregnancy
All women should be screened w/ a urine cx at the first PNC visit
LCE is common on urine dips in pregnant
women
only
need to
tx
presumptively and send cx if other findings such as nitrites, blood, etc. and/or if
sx’s
UTI
tx
in pregnancyCephalexin 500 mg po qid X 7 daysNitrofurantoin 100 mg po qid X 7 daysAmoxicillin/clavulanate 875/125 mg po bid X 7 daysTMP/SMX DS bid X 7 days can be used in the second trimester onlyIf two UTIs or one pyelonephritis, prophylaxis w/ cephalexin 500 mg po qhs indicated until delivery
Slide40What are some common pre-existing health issues that affect pregnancy?
Chronic HTN is common in women of reproductive age
Sometimes not officially diagnosed before onset of pregnancy
BP of 140/90 or greater at < 20
wks
GA
Per
ACOG HTN in Pregnancy 2013 Task
Force:
Should have a baseline set of PIH labs and 24h urine for protein or urine p/c ratio
Fetal surveillance is indicated if medications are required or “other underlying medical conditions that affect fetal outcome”
BP goal in pregnancy = 120-160/80-105
Start or increase
tx for 160/105 (some say 150/100) Make sure using accepted drug in pregnancyLabetalolNifedipine XLMethyldopacHTN confers increased risk for developing pre-eclampsia
Slide41What are some common health
issues that affect pregnancy?
Pre-
eclampsia
BP
>
140/90 X2, 4h apart and EITHER
proteinuria (300mg in 24h or urine p/c ratio 0.3), OR
Lab
abormalities
: platelets <100K, transaminases 2X ULN
,
creatinine
doubled or 1.1, OR Sx’s: HA, visual changes, pulmonary edemaMonitor with 2X/wk BP checks, fetal surveillance, US for growth, weekly labsDeliver at 37 wks if no severe features (or if gestational HTN)Pre-eclampsia with severe featuresSymptoms: HA, visual changes, pulmonary edema, RUQ or epigastric painPlatelets < 100K, transaminases 2X ULN, creatinine doubled or 1.1BP > 160/110 X 2
Slide42What are the basic prenatal labs?
Blood type (ABO and Rh) and antibody screen
CBC
Treponema
pallidum
antibody
HIV PCR
Rubella antibody (IgG) titer
Varicella antibody (IgG) titer (if no prior history of vaccination or documented infection)
Hepatitis B surface antigen
Gonorrhea and chlamydia PCR
Screening urine culture
Genetic screening/testing, if desiredGlucose testing (hgbA1c at presentation, then 24-28 week screening)Group B Strep culture at 35 weeks
Slide43What are some common prenatal lab abnormalities and how are they managed?
Rh negative status
Verify that initial antibody screen is negative
Repeat antibody screen at 28
wks
GA
If antibody screen remains negative at 28
wks
, give
Rhogam
Rhogam
also indicated for vaginal bleeding, procedures such as
amnio
or ECV, significant abdominal trauma, and following delivery (if fetus is Rh positive)
Slide44What are some common prenatal lab abnormalities and how are they managed?
Positive antibody screen
Initial screen sometimes too weak to identify or titer
repeat in 3-4 weeks
Once identified with or without titer, consultation w/ FM-OB or MFM recommended
Follow-up may include
FOB antigen testing (if paternity is certain)
Serial antibody titers
MCA
D
opplers
Slide45What are some common prenatal lab abnormalities and how are they managed?
Anemia
I
nitial CBC, plus repeat HCT at 28
wks
Most will be iron-deficiency based upon low MCV
PNVs have FeSO4
324 mg
Add additional 1-2 tablets of FeSO4 324 mg
Ferrous
gluconate
is sometimes better tolerated
Offer scheduled docusate (Colace), encourage increased H
2O and fiber intake, polyethylene glycol (Miralax)Can do additional iron studies or other labs if unclear type of anemia
Slide46What are some common prenatal lab abnormalities and how are they managed?
Positive
treponema
antibody testing
RPR is processed reflexively by lab
Obtain treatment
hx
from patient and verify with public health department
Recommend consultation with FM-OB or MFM for positive RPR titers, given important pregnancy implications
Slide47What are some common prenatal lab abnormalities and how are they managed?
Rubella equivocal or non-immune titer
P
atients offered MMR following delivery
Recommended to obtain testing as part of pre-conception counseling, to allow vaccination
If non-immune “avoid contact with febrile children w/ rashes”
Varicella non-immune titer
Only test those who do don’t have
written proof of immunity either by patient record of chicken pox or proof of the two vaccine series
T
iters do not accurately reflect immunity after vaccination (don’t test people who have record of vaccination)
Vaccinate after delivery (one at discharge and one at 4 weeks postpartum)
Slide48What are some common prenatal lab abnormalities and how are they managed?
Unless already diagnosed, screen all women for gestational diabetes at 24-28
wks
Current ACOG recommendation is non-fasting 50g 1hGTT (abnormal
>
135-140—at UNM we have decided to use 130)
If 1hGTT is abnormal, then obtain fasting 3hGTT
Threshold values = 95/180/155/140
One abnormal value = glucose intolerance
Two abnormal values = gestational diabetes
Slide49What are some common prenatal lab abnormalities and how are they managed?
Management goals for gestational diabetes
Fasting glucose < 95
2h post-prandial < 120
1h post-prandial < 140
If meds started, needs fetal surveillance at 32
wks
Serial ultrasounds for growth
Delivery at 39
wks
for GDMA2, 40-41
wks
for GDMA1 (occasionally earlier if macrosomia)
Slide50What are some common prenatal lab abnormalities and how are they managed?
Group B Strep
Screen at 35
wks
Result considered valid through remainder of pregnancy
If positive urine cx for GBS, consider positive throughout pregnancy and do not re-screen at 35
wks
No indication to treat before labor (except UTIs)
If PCN allergy, request sensitivities for positive cx
Re-screen each pregnancy, unless infant affected by GBS disease in prior
pregnancy
Slide51What are some important lifestyle counseling topics for prenatal care?
Exercise
Moderate intensity X 30 min/day
Avoid risk of abdominal trauma from falls, etc.
May decrease risk of pre-
eclampsia
, GDM,
macrosomia
Good options: walking, swimming, stationary cycling
If weight lifting, low weights and high reps preferred
P
recautions:
thermoneutral
environment, hydration, watch for PTL/SAB sx’s, stop if pre-eclampsia or IUGR
Slide52What are some important lifestyle counseling
topics for prenatal
care?
Safety: seat belt use, domestic violence
Intimate partner violence
Pregnancy is a risk factor for IPV
Violence occurs in 7-20% of pregnancies
5% of female homicide victims were pregnant in US study
How to screen (sensitivity 65-70%)
Have you been hit, kicked, or otherwise hurt by someone within the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe now?
Slide53What are some important lifestyle counseling topics for prenatal care?
Exposures
: tobacco, alcohol, other substances of
abuse
Consider a progressive approach: caffeine, tobacco,
etoh
, drugs
4 P’s
Parents: Did any of your
parents
have a problem with alcohol or other drug use?
Partner: Does you
partner
have a problem with alcohol or drug use?Past: In the past, have you had difficulties in your life because of alcohol or other drugs, including prescription medications?Pregnancy: Have you drunk any alcohol or used other drugs in the current pregnancy?
Slide54What are some important lifestyle counseling topics for prenatal care?
Nutrition
Food safety
Only fully cooked meat, fish, eggs
No unpasteurized milk products
Wash fruits and veggies
No raw sprouts (bacteria in the cracked seeds can’t be washed out)
Avoid excessive mercury from fish
swordfish, shark, king mackerel, tilefish, tuna steaks = high mercury
12
oz
per week of other fish (6
oz
max of alabcore tuna)Caloric intake increase340 kcal/day in second trimester450 kcal/day in third trimester
Slide55What are some important lifestyle counseling topics for prenatal care?
Specific nutrients
Iron: 30 mg/day if not anemic (met by most PNV)
Calcium: 1000 mg/day (same in lactation)
Folic acid
0.4 – 0.8 mg/day supplementation for month prior and first 3 months of pregnancy
0.6 mg/day thereafter in pregnancy
Vitamin D
no need to screen unless risk factor
optimal pregnancy level not known, but recommendations for at least 20ng/mL for 25-OH-D level
400 IU recommended supplement (in most PNV), but 1000-2000 IU probably safe
Slide56=OBprenatalteaching_6_8wksDiscussed
with
patient:
Nutrition
,
weight
gain guidelines, physical/sexual activity,
work/stress management
Self-care
including vitamins, seatbelts, dental
care
Normal
PNC activities/labs/visits and optional
testingFirst trimester discomforts and danger signs=OBprenatalteaching_10_12wksDiscussed with patient: Results/labs from first visitFetal growth and developmentPt teaching re: specific complaints of:____________First trimester danger signs reviewedHow can I easily document patient education topics addressed?
Slide57How can I easily document patient education topics addressed?
Slide58What is fetal surveillance?
Fetal surveillance consists of
1-2x/week non-stress test (NST) and weekly amniotic fluid index
Sometimes 1-2x/week biophysical profile used instead of NSTs
Often serial US (q3-4
wks
) for
growth
Timing of onset depends on indication for monitoring, but often at 32
wks
GA
Slide59What conditions are indications for
fetal
surveillance?
Post-dates (41 0/7
wks
GA until delivery)
GDMA2 (i.e. on meds)
Type 2 DM
Chronic HTN on meds, gestational HTN,
pre-eclampsia
IUGR
Oligohydramnios
or
polyhydramniosOngoing use of substances of abuseSignificant AMA (> 40 y/o)Hx of third trimester IUFD
Slide60What are the considerations in counseling women for TOLAC vs. repeat c/s?
Good candidates for TOLAC
Prior vaginal delivery
C/s indication
i
s “non-recurring”
Breech
Twins
Fetal intolerance of labor
No indication (purely elective)
Desires large family
Slide61What are the considerations in counseling women for TOLAC vs. repeat c/s?
Obtain operative report, if possible
Verify low transverse uterine incision
Verify no extensions into contractile portion of uterus (inferior extensions are usually okay), incision not “
T’d
”, etc.
Look at indication for cesarean section
Consider whether double-layer uterine closure performed
Date of procedure
If no operative report available
Most c/s’s at term are low transverse uterine incisions
Skin incision does not correlate with uterine incision
Increased suspicion for classical or
T’d incisionsVery pretermTransverse fetal presentation (especially back-down)Anterior placenta previa
Slide62What are the considerations in counseling women for TOLAC vs. repeat c/s?
Risk of uterine rupture is thought to be
0.8 % with one prior low transverse uterine incision
1% with two prior low transverse uterine incisions
3-7% with prior classical uterine incision
Risk of “poor neonatal outcome” if uterine rupture occurs in labor is 10%
Hypoxic ischemic encephalopathy
Stillbirth or neonatal death
Failure and rupture rate increase with induction of labor (doubled?), so patients need to be re-counseled and needs to be documented
Recommend TOLAC consent be signed by 32
wks
Patients can change mind when present in labor
Slide63Slide64Goal: Update your knowledge of standard prenatal care recommendations
Explain the recommended approach for establishing the best
estimated due date
Succinctly describe for patients the options for
genetic screening and testing
in pregnancy
Discuss common
historical health issues
which have relevance to the current pregnancy
Describe common
prenatal laboratory abnormalities
and their management
List important
counseling and education topics in prenatal care Discuss frequently encountered indications for fetal surveillance Describe an approach to counseling women regarding trial of labor after cesarean section
Slide65References
ACOG Task Force on Hypertension in Pregnancy. 2013.
ACOG Practice Bulletin No. 137: Gestational Diabetes Mellitus. August 2013.
ACOG Committee Opinion No. 545: Noninvasive Prenatal Testing for Fetal Aneuploidy. December 2012.
ACOG Committee Opinion No. 524. Opioid Abuse, Dependence, and Addiction in Pregnancy. May 2012.
Hanson L,
VandeVusse
L, Roberts J,
Forristal
A. A Critical Appraisal of Guidelines for Antenatal Care: Components of Care and Priorities in Prenatal Education. Journal of Midwifery & Women’s Health. Vol. 54, No. 6. December 2009.
Kirkham C, Harris S,
Grzybowski
S. Evidence-Based Prenatal Care: Part I. General Prenatal Care and Counseling Issues. American Family Physician. Vol. 71, No. 7.
April 2005. Kirkham C, Harris S, Grzybowski S. Evidence-Based Prenatal Care: Part II. Third Trimester Care and Prevention of Infectious Diseases. American Family Physician. Vol. 71, No. 8. April 2005. Artal R. Recommendations for exercise during pregnancy and the postpartum period. UpToDate. Gillen-Goldstein J et al. Nutrition in pregnancy. UpToDate