FUNDAMENTALS OF OBSTETRICS

Christine Pecci, MD Associate Clinical Professor UCSF Department of Family and Community Medicine March 2017

No disclosures

OBJECTIVES Describe the group prenatal care model Review criteria for ultrasound vs LMP dating Review management of women at risk for

preterm delivery Describe guidelines for diagnosis, treatment and

management of preeclampsia, gestational diabetes and thyroid disease in pregnancy

List infections in pregnancy and how to manage or prevent these from occurring

PRENATAL CARE MODELS: DO WE KNOW WHAT’S BEST? Traditional care-ACOG

Q 4 wk visits until 28 weeks Q 2 wk visits until 36 weeks Q 1 wk visits until delivery

Traditional care- ICSI 8-11 visits total 6-8 wks, 10-12 wks, 16-18 wks, 22 wks, 28 wks, 32

wks, 36 wks, 38-41 wks Group Prenatal Care

Group of 5-12 patients x 2 hours q 2-4 wks

GROUP OR TRADITIONAL PRENATAL CARE? Similar rates of PTD, NICU admission and

breastfeeding initiation rates African American women with significantly lower

PTD rate* but not among Latina Decreased rate of LBW overall**

No harm in doing group care and likely benefit in

certain groups

Carter et al OB GYN Sept 2016

Tanya is a 23 yo G1P0 who presents for early pregnancy care. EGA 10 1/7 wks by a sure LMP

She had a visit to ED for nausea and vomiting

Given 1 liter NS Electrolytes were normal TSH 0.1

NAUSEA AND VOMITING IN PREGNANCY Nausea in 50-80% Vomiting/retching 50% Hyperemesis gravidarum 0.3-3%

Persistent vomiting Weight loss Ketonuria Usually electrolyte, thyroid, liver abnormalities

Lower rate of miscarriage

ACOG Practice Bulletin April 2015

TREATMENT OF N/V IN PREGNANCY Multivitamin x 3 months before conception Ginger may decrease nausea Acupuncture/acupressure- no difference in RCTs First line treatment pyridoxine +/- doxylamine Metoclopromide, ondansetron second line

Limited safety data, but overall risk low Oral corticosteroids used as last resort– avoid 1st

trimester

ACOG Practice Bulletin April 2015

NORMAL THYROID FUNCTION AND PREGNANCY Hcg stimulates TSH receptor, increasing thyroid

production and decreasing TSH Total thyroid hormone levels increase due to

elevated thyroid-binding globulin (TBG) Free T4 unchanged (direct assays ok but many labs use

automated assays which can be inaccurate) TSH is a reliable indicator of maternal thyroid

status (American Thyroid Association) First trimester 0.1-2.5 mIU/L Second trimester 0.2-3.0 mIU/L Third trimester 0.3-3.0 mIU/L

HYPERTHYROIDISM IN PREGNANCY Avoid meds in 1st trimester If medication needed, use PTU

risk of liver failure Risk face and neck cysts

Consider changing methimazole after 16 wks (aplasia cutis) other congenital malformations

Smallest possible dose as medications cross placenta and can be more potent for fetal thyroid

Target: at or just above upper range of normal Moniter TSH/T4 every 4 wks if on medication

HYPOTHYROIDISM Case control trials showed hypothyroidism

associated with low IQ in the fetus RCTs do NOT confirm that treatment of

subclinical hypothyroidism improves neurocognitive outcomes Both initiated Rx after first trimester

Universal screening for thyroid disease in pregnancy is not indicated* Increased pregnancy loss with elevated TSH,

especially if TPO ab elevated Effectiveness of Rx not yet proven Maybe need to screen 4-7 wks?

*ACOG, Endocrine Society, American Association of Clinical Endocrinologists

RECOMMENDATIONS Treat if TSH >10 TSH>2.5 check TPO Ab status ?treat if TPO Ab+ and TSH >2.5 Don’t treat if TPO neg and TSH > upper nl <10

If treating

Target lower half of preg specific range or <2.5 Measure q4 wks in pregnancy then at least once near

30 wks

American Thyroid Association 2017

SUPPLEMENTATION AND PREGNANCY 50-85% need increase in thyroid replacement Preconception treat to <2.5 Should increase dose by 25-30% ASAP post

conception (can give two extra pills/wk)

Postpartum following delivery go back to pre-pregnancy dose and recheck in 6 wks

If Rx started in pregnancy with nl TSH reasonable to stop and recheck in 6 wks

LMP VS. US DATING Tanya also had an US done in the ED Crown-rump length = 9 2/7 weeks LMP 10 1/7 wks

6 days different than EDD based on LMP

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

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?

Characteristics of screening tests:T21

Dashe, Jodi MD Obstet Gyn 2016

Options for screening

First Trimester Second Trimester hcg + PAPP-A hcg + AFP + estradiol + inhibin 11-14 wks 15-22 wks Can be combined w NT Anatomy scan AFP in 2nd trimester for NTD Includes AFP

• 1st trimester screening gives the patient early results • 2nd trimester screening good for late entry to care • DON’T do both independently • CAN do combined (7 serum markers + NT)

COMBINED 1ST AND 2ND TRIMESTER SCREENING Sequential testing

Stepwise high risk offered diagnostic testing after 1st trimester Others get results after second trimester Contingent highest risk offered diagnostic testing after 1st tri lowest risk reassured- no further testing Others get results after 2nd trimester

Integrated testing

CELL-FREE DNA Circulating DNA fragments placental in origin

from apoptotic trophoblasts Can be done anytime after 9-10 wks gestation Available in 7-10 days Best for trisomy 21 and 18 but also screens for

trisomy 13 and sex chromosome aneuploidies Gender Can be used as primary or secondary screening

AJOG June 2016 SMFM Consult Series

Dashe, Jodi MD Obstet Gyn 2016

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

INITIATE ASA 12-28 WKS FOR HIGH RISK History of pre-eclampsia, esp if adverse outcome Multi-fetal gestation Chronic hypertension Diabetes type 1 or 2 Renal disease Autoimmune disease (SLE, APS)

Patient with history of preeclampsia <34 wks

Prevalence 40% NNT 1:20

Practice Advisory on Low-Dose Aspirin and Prevention of Preeclampsia: Updated Recommendations July 11 , 2016

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

WHEN TO DELIVER? 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

WHEN TO DELIVER? 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 Anti hypertensive meds only for > 160/110 Administer steroids prior to delivery

POSTPARTUM FOLLOW-UP 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

ALL patients should receive education on warning signs

ROUTINE US 18-22 WKS Confirms dating if not already done Anatomy scan ? Cervical length

Universal screening not indicated

SCREEN FOR GDM AT 24-28 WKS

Overall incidence of DM in pregnancy 6%

90% of these are GDM Early screening- if

prior GDM, known impaired fasting glucose, BMI >30

GESTATIONAL DIABETES HAPO trials show continuous relationship-

neonatal hypoglycemia, macrosomia Increased hyperbilirubinemia, operative delivery,

shoulder dystocia 2010 International Association of Diabetes and

Pregnancy Study Group (endorsed by ADA) (92, 180, 153) No data regarding therapeutic intervention

ACOG Practice Bulletin Aug 2013

DIAGNOSIS OF GDM 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

MANAGEMENT AND TREATMENT QID fingersticks Goal <140 on 1 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

WHEN TO DELIVER? Induce at 39 weeks if pre-gestational or

gestational DM on meds For well controlled GDM without meds, unclear

whether induction is indicated.

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 4-12 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

Laboratory-confirmed Zika virus disease cases reported to ArboNET by state or territory (as of February 1, 2017)

ZIKA VIRUS IN PRE/POST CONCEPTION Pre-conception

women: wait 8 wks after sx start or last exposure Men: wait 6 months

If pregnant: Avoid travel to active Zika virus areas or take measures to avoid mosquito bites

Use condom if partner is travelling to Zika areas For those living or travelling frequently to Zika

areas, do testing Ask about travel to endemic countries Protected from future infections

ZIKA TESTING Test those with clinical illnesses (2 or more sx)

during or within 2 weeks of travel RNA NAT and Zika Ig M

Offer RNA NAT to pregnant women 2-12 weeks after travel if they are Zika IgM

Testing done by CDC and state health depts

ZIKA AND FETAL CONCERNS Microcephaly (at birth or postnatally) Congenital Zika Syndrome

Severe microcephaly where skull partially collapsed Specific pattern of brain damage and decreased brain

tissue Damage to back of eye Joints with limited ROM (club foot) Hypertonia

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

ZIKA RESOURCES https://www.cdc.gov/zika/hc-providers/pregnant-

woman.html Call 770-488-7100 and ask for the Zika

Pregnancy Hotline or email ZIKAMCH@cdc.gov

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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

Tanya declined the Tdap and flu shot pregnancy because she was afraid of it hurting the baby.

Postpartum 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 Preconception (thyroid adjustment, zika travel)

Watch for pregnancy related diseases Translates to risk of these diseases later in life Some interventions indicated early in pregnancy

We have interventions to prevent perinatal transmission of disease