the right stuff: applying evidence to routine prenatal · pdf filethe right stuff: applying...

The Right Stuff: Applying Evidence to Routine Prenatal Care

William Ehman MDOctober 27, 2011

Learning Objectives

• Current evidence based recommendations for routine prenatal care

• The purpose & use of:▫ BC Maternity Care Pathway, (care

providers)▫ Pregnancy Passport (women)

• Practical advice on some common issues

• Immerging antenatal assessment options

Maternity Care Pathway2010

“philosophy: pregnancy is a normal physiological process ... interventions should have known benefits and be acceptable to pregnant women”

http://www.perinatalservicesbc.ca#19 – Maternity Care Pathway

• High quality• Accessible• ‘Woman centered’

Maternity Care Enhancement Project 2004

The Care

Who Provides Care: Canada?

Prenatal Care

OB FP MW RN

Canada 58% 34% 6% 1%

B.C. 38% 51% 10% 1%

Birth

OB FP MW RN

Canada 70% 15% 4% 5%

B.C. 58% 27% 6% 3%

Canadian Maternity Experiences Survey, 2009http://www.publichealth.gc.ca/mes

Developmental Origins of Health & Disease

Adverse Pre-pregnancy

health

Adverse Intrauterine

EnvironmentAdult Disease

CHD, Stroke,Hypertension

Insulin resistanceDyslipidemia

Anxiety/depression

Adult DiseaseCHD, Stroke,Hypertension

Insulin resistanceDyslipidemia

Anxiety/depression

Adverse Postnatal

Environment

Modified from Dr. A Bocking, Chair Dept. O&G, U of T

%%

BirthweightBirthweight

Prevalence of future diabetesPrevalence of

future diabetes

PSBC Guideline Maternity Care Pathway 2010

Where the Pathway starts:

Why?• 50% unplanned• Early organogenesis

▫ Placenta at 7d▫ n. tube closes @ 28d


(and Prenatal)

• Folic Acid- 0.4-5mg/d 3m before conception

• Multivitamin - may reduce anomalies, SGA & PTB (BMI<25) 1

• Vit. A ≤ 5000 IU (avoid >1 MultiV/day)

• Vit. D - 400-2000 IU/d▫ Risk factors:melanin, sun exposure, dairy intake

▫ Effect: fetal growth, ossification & enamel, cardiomyopathy• ?400 vs. 4,000 IU in TM 2&3 GDM, preeclampsia and PTB2

• Calcium – 1000 mg/d

• Iron: 15 to 20 mg supplement3

▫ North American diet = 15mg/d; pregnant need is ~ 27 mg/d

1Catov J, Am J Clin Nutr. Sept. 20112Wagner, Ped Acad Soc, Van. BC, May, 2010

3Health Canada, 2010

Preconception/Prenatal - Supplements

• Wash▫ fruits & vegetables

• Eat▫ fully cooked meat & eggs▫ avoid pate, dried meats raw fish, shellfish (oysters & clams) unpasteurized dairy, raw eggs

• Avoid▫ Direct contact with soil, animal feces

Food Safety:Toxoplasmosis/Listeriosis/Salmonella:

• Good: omega-3FAs: fetal brain/eye

• Bad: Mercury

Fish (the good & the bad)

Fish with High Mercury Shark, Swordfish, King Mackerel, or Tilefish

300gm (12oz)(~2 meals)of Low-Mercury Fish/week

Cod, salmon, canned light tuna, rainbow trout, Atlantic mackerel, sole, shrimp, crab, scallops, pollock, and catfish etc. Note: Albacore "White" tuna contains more mercury. Limit 150 gm (6oz) (~1 meal) per wk

Health Canada, FDA, EPA

“HERBS TO AVOID OR USE WITH CAUTION DURING PREGNANCY”

• Angelica - stimulates suppressed menstruation

• Black Cohosh - uterine stimulant - mostly used during labor

• Blue Cohosh - a stronger uterine stimulant• Borage oil - a uterine stimulant - use only

during the last few days of pregnancy• Comfrey - can cause liver problems in

mother and fetus - use only briefly, externally only, for treating sprains and strains

• Dong Quai - may stimulate bleeding• Elder - do not use during pregnancy or

lactation• Fenugreek - uterine relaxant• Goldenseal - too powerful an antibiotic for

the developing fetus, also should not be used if nursing

• Henbane - highly toxic• Horsetail - too high in silica for the

developing fetus

• Licorice Root - can create water retention and/or elevated blood pressure

• Motherwort - stimulates suppressed menstruation

• Mugwort - can be a uterine stimulant• Nutmeg - can cause miscarriage in large

doses• Pennyroyal Leaf - stimulates uterine

contractions (NOTE: Pennyroyal essential oil should not be used by pregnant women at any time!) - do not handle if pregnant or nursing

• Rue - strong expellant• Shepherd's Purse - used only for

hemmorhaging during/after childbirth• Uva Ursi - removes too much blood

sugar during pregnancy and nursing• Yarrow - uterine stimulant

Waltz, The Herbal Encyclopedia, http://www.naturalark.com/herbpreg.html

• maximum daily caffeine intake = 2001-300 mg2

CaffeineFoods and Beverages Caffeine

(mg)Coffee (8 oz.)Brewed, dripInstant

13776

Tea (8 oz.)BrewedInstant

4830

Cola & caffeinated drinks (12 oz) 37

Hot cocoa (12 oz) 10

Chocolate Milk (8 oz) 8

1 Food Standard Agency , UK2 NICE 2008

Underweight (BMI <18.5)• 6%1

• PTB, SGA, Neonatal M&M, adult illness

OW/Obese (BMI>25&30)• 35% (21 + 14%)1

• Maternal:▫ GDM, GH, TED, dystocia, C/S, infection

• Neonate:▫ LGA, asphyxia, PNM, congenital defects

1Canadian Maternity Experiences Survey, 2009; http://www.publichealth.gc.ca/mes

1. IGT2. lipids -prostocylin &

peroxidase→vasoconstriction & platelet aggregation

3. O2 with sleep apnea4. awareness of FM

Weight Before Pregnancy

• family history, ethnicity▫ offer carrier screening and/or management

• With 3 pregnancy losses:▫ 3.5%-5% risk of mat. chromosomal rearrangement▫ 1 %-2% risk of a paternal rearrangement.

Genetic screening & family history

Phenylketonuria ThrombophiliaHemophilia A Muscular dystrophies Cystic fibrosis Mental retardationTay-Sachs Hemoglobinopathies

Substance:• Screen• Council, refer• Harm reduction

Medications:• Prescription• OTCs

E.g. Non ASA NSAIDs: In early preg. associated with:• cardiac septal defects1

• spont. abortion (OR 2.43, 95% CI. 2.12–2.79).2

1Ofori , Birth Defects Res B Dev Reprod Toxicol 2006;77:268-79.2Nakhai-Pour CMAJ Sept. 2011

Tobacco• Screen all1

Alcohol “insufficient evidence to define

any threshold for low-level drinking in pregnancy.”2

1BCPHP Guideline 092SOGC ‘10

Toxins/Teratogens• h. metals, solvents, pesticides, etc.

Infections• Screen for periodontal, urogenital, STIs• Counsel re: TORCH• Hx of STI, substance use, Soc/Economic

herpes

syphilis

toxoplasmosis

rubellaCMV

Vaccination• Preconception:▫ Update▫ Seasonal influenza

• Inactivated vaccines & toxoids - are safe

• Live & attenuated virus vaccines▫ Contraindicated in pregnancy▫ Inadvertent use not indication to terminate▫ If given: delay conception ≥4 wks (SOGC 2009)

Inactivated & Toxoids

hepatitis A and B, pneumococcus, meningococcus, cholera, plague, typhoid, diphtheria / tetanus, Japanese encephalitis, influenza

Live & live-attenuated

measles, mumps, rubella, varicella, polio, yellow fever, rabies & nasal spray influenza

In Due Time: Why Maternal Age Matters

≥35 (18% of births) • Risks ( with age); greatest - 1st time mothers ≥40• For mother

▫ BP, PET, DM, PP, C/S▫ ≥35 (compared to 20-34): AVB(+28%), abruption(+36%)

• For babies:▫ PTB, LBW, SGA, chromosomal/congenital abnormality

Data from 2006-2009https://secure.cihi.ca/estore/productFamily.htm?locale=en

&pf=PFC1656

Maternal Age

Tietze C: Reproductive span and rate of conception among Hutterite women.

Fertility and Sterility 1957;8:89-97.

7% 11%

33%

87%

0%10%20%30%40%50%60%70%80%90%

100%

30 35 40 45

Infertility Rate

• Risk IUFD:

Bahtiyar et al, Am J Perinatol 2008 ;25:301–304

Age (years)

Risk of IU Fetal Death Compared to 25-29 (OR)

30 - 34 1.24

35 - 39 1.45

40 – 44 3.04

40-44 yr @39wks 25-29 yr @42wks=


(≥ 5 in UpToDate)

What are the time sensitive and important elements of prenatal care?

She is now pregnant!

SIPS Serum Integrated Prenatal Screen10-13+6: PAPP-A 15-20+6 : AFP, uE3, hCG and inhibin-A

IPS Integrated Prenatal ScreenSIPS + NT

QUAD One blood test15-20+6 : AFP, uE3, hCG and inhibin-A

NT Nuchal Translucency 11-13+6 (optimal: 12-13+3)

CVS Chorionic villus sampling 10+3 – 12+6 wks

Amniocentesis ≥15 wks

Summary of Prenatal Genetic Screening Options (e.g. BC (2009)

*

*Accurate dating is essential!PSBC Guideline Maternity Care Pathway 2010

Abnormal Markers May Predict Complications

SOGC CPG No. 217, October 2008 ;Dugoff; Obstet Gynecol 2010;115:1052-61

Analytes:• 1st TM(10–14wks): PAPP-A, hCG• 2nd TM(15–21wks): hCG, AFP, Estriol, Inhibin

Conditions associated:• SA, SB, NN death, LBW, IUGR, oligo., NTD,

abd. Wall def., LGA, PTB, PreEcl, PPrevia

What to do?• Consultation to determine surveillance & Rx

▫ Detailed US▫ Uterine artery Doppler (22-24wks) UA notching +/or Resist index

Ut. A Doppler waveforms:

Normal

Abnormal

The Model of Care

16w

41w40w39w38w37w

36w34w32w30w

28w24w

Memorandum on Antenatal Clinics UK Min. of Health, 1929

Traditional

A New Model of Care?

Could possibly identify:• 90% aneuploides• Most major structural

abnormalities• Risk for SB/spont. abortion• Gestational DM• Fetus at risk for:▫ PTB▫ SGA▫ macrosomia

11-13 wk: mat. hx, tests, US

Specialist care 12-34w

20w

37w

41w

From Nicolaides K, Prenat Diagn 2011

(0-14wks)


Work – risk factors1

• 36 hrs/wk or 10 hrs/day• standing(>3-6h/shift), heavy lifting, noise, mental stress

Hot Tubs/Baths• water temp < 39 2

Stretchmarks• Prevention: nothing proven▫ May harm: Retinoids, Salicylic acid,

Soy(chloasma)

INSTITUTE FOR CLINICALSYSTEMS IMPROVEMENT

1Institute for Clinical Systems Improvement, 13th Ed. Aug. 20092 ACOG

Exercise• “All without contraindications encouraged to participate in

aerobic and strength-conditioning exercises as part of a healthy lifestyle during their pregnancy.” (II-1, 2B)1

• “choose activities that minimize the risk of loss of balance and fetal trauma. (III-C)”1 eg. extensive jumping, contact sports

• “at least 30 min. most days”2

• Core, talk test, temp. not > 38°

Absolute Contraindications Relative ContraindicationsRuptured membranes Previous spontaneous abortionPreterm labour Previous preterm birthHypertensive disorders of pregnancy Mild/moderate cardiovascular disorderIncompetent cervix Mild/moderate respiratory disorderGrowth restricted fetus Anemia (Hb <100 g/L)High order multiple gestation (≥ triplets) Malnutrition or eating disorderPlacenta previa after 28th week Twin pregnancy after 28th weekPersistent 2nd or 3rd trimester bleeding Other significant medical conditionsUncontrolled type 1 DM, thyroid, CV, Resp. Disease or systemic disorder

1SOGC CPG No. 129, June 2003 2http://www.healthypregnancybc.ca/page194.htm

Screening/Diagnostic Tests (0-14wks)

Test LORBlood Group, Rh, Antibodies C Hemolytic disease

Hb, MCV B Anemia, hemoglobinopathyHIV A reduce transmission to NB

Rubella Ab Titre B PP vaccination if not immune

STS A

HBsAg A Guide Mat. & NB care

TSH B Offer all

Chlamydia screen B Offer to all

Gonorrhoea A Offer to all

Midstream urine C/S AC

Early pregnancy - allRecurrent UTIs - each TM A Good evidence for

B Fair evidence for

C Conflicting

D Fair evidence against

I Insufficient


Screening/Diagnostic Tests (0-14wks)

Test L.O.R.

Hep C testing A Recommend with risk factors

GTT or FBG A With risk factors (FH, Obese, etc.)

Pap test B If indicated

B19, Mumps, Toxoplasmosis, CMV, etc

I No routine testing

B If women exposed/symptoms

TWEAK B Screen alcohol use, most sensitive in 1st

15 wks

A Good evidence for

B Fair evidence for

C Conflicting


I InsufficientPSBC Guideline Maternity

Care Pathway 2010

Procedure L.O.R.

BP C

Fetal Movement BAB

Healthy: 26-32 wks be aware of mov’tsWith risk factors FM counting-if<6 mov’ts/2hrs – AN testing ASAP

FHR C

Symphysis Fundal Ht B Plotting on graph will asses growth

Urine dip for protein BCA

Early pregnancy to screen renal diseaseScreen for pre-eclampsia (low risk)Screen when suspect pre-eclampsia

Weight measurement IB

To monitor esp. Under/over weightTo assist obese women

Routine Prenatal Care at each Appointment

A Good evidence for

B Fair evidence for

C Conflicting


I Insufficient


& CBC


C: CDA - recommendedI: SOGC - “acceptable” to not screen low risk women

The Passport


PregnancyPassport1. Things to

discuss & expected care

PregnancyPassport2. Goals &

decision points

PregnancyPassport3. Resources

Thank you

William Ehman MD

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