undamentals of obstetrics - ucsf cme
TRANSCRIPT
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
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 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
okay?
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
offer 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