Routine of Prenatal Care

20/11/2015
DynaMed
Routineprenatalcare
Updated2015Oct0506:46:00AM:supervisedprenatalexerciseassociatedwith
reducedriskofhavinglargeforgestationalagenewborn(ObstetGynecol2015May)view
update Showmoreupdates
RelatedSummaries:
Prenatalultrasoundscreening
Hypertensivedisordersofpregnancy
Gestationaldiabetesmellitus(GDM)
Posttermpregnancy
Pretermlabor
Managementofroutinelabor
Overview:
pregnancymaybeconfirmedwithpregnancytest(urineorserum)andcombinationof
historyandphysicalexam
mostwomenindevelopedcountrieshave712prenatalvisits
prenatalvisitsrecommendedonamonthlybasisforuncomplicatedpregnanciesthrough
about28weeksgestation,every23weeksfrom2836weeksgestation,thenweeklyuntil
delivery
elementsofprenatalvisitscontinuedthroughoutpregnancy
trackweightgainduringpregnancyatallvisits
bloodpressuremeasurementgenerallysuggestedateveryprenatalvisittoassessfor
preeclampsia
performauscultationoffetalheartrateateachvisitstartingbetween1012weeks
gestationforconfirmationofviablefetus(noevidenceofotherclinicalorpredictive
value)
performfundalheightmeasurement(incm)ateachprenatalvisitbeginningat20weeks
gestationtomonitorfetalgrowth
assesslowerextremitiesforedema
considerurinalysis
trimesterspecificprenatalcare
prenatalcareinfirsttrimester
determinebaselinebodymassindex(BMI)atinitialprenatalvisit,andtrackweight
gainduringpregnancyatallsubsequentvisits
providecounselingtoguideoptimalweightgainduringpregnancybasedonpre
pregnancyweight
http://www.bidi.uam.mx:5647/dynamed/delivery/printcitation?expand=secConfirmingPregnancy,secDeterminingGestationalAge,secTrimesterSpecific
1/85
20/11/2015
DynaMed
counselpatientonpropernutrition,includingsupplementationwithfolicacid400
800mcgorally/day(AAFPGradeA)
30minutesofmoderateexercise/dayonmostoralldaysoftheweek
recommendedforpregnantwomenwithoutmedicalorobstetriccontraindications
performriskassessment(atpreconceptionvisitorfirstprenatalvisit)viapatient
history
performroutinefirsttrimesterultrasoundinallwomento
evaluatepresence,size,location,andnumberofgestationalsac(s)
determinegestationalage,mostaccuratelyidentifiedbycrownrumplength
between10weeksand13weeks6daysgestation(ACOGLevelA)
initialprenatalbloodtestsmayinclude
maternalbloodtypeandRhantibodystatus
varicellaantibodytiterifnohistoryofchickenpoxinfection
completebloodcount(CBC)toscreenforanemia(treatwithironifindicated)
hemoglobinelectrophoresisinwomenofAfrican,SoutheastAsian,and
Mediterraneandescenttoscreenforhemoglobinopathies(RBCindicesfromCBC
sufficientinallotherwomen)
thyroidstudies(indicatedinwomenatriskforthyroiddisease)
hepatitisB,HIV,andsyphilisinallwomen
screenforasymptomaticbacteriuriawithurinecultureatfirstprenatalvisitorbetween
1116weeksgestation,andtreatifindicated
considerpreconceptionorearlyprenatalscreeningforsexuallytransmittedinfections,
includinggonorrheaandchlamydiaasindicatedbasedonriskfactorsandage
(chlamydiatestingindicatedforallwomenaged25years)
offergeneticscreeningandinvasivediagnostictestingtoallwomenpresentingfor
prenatalcarebefore20weeksgestation,regardlessofmaternalagecounselwomen
ondifferencebetweenscreeningandinvasivediagnostictesting(ACOGLevelB)
prenatalcareinsecondtrimester
performsecondtrimesterultrasoundtoevaluatefetalanatomyandpresentation,
amnioticfluidvolume,cardiacactivity,placentalposition,fetalbiometry,andfetal
number
optimaltimingofsingleultrasoundexam(inabsenceofspecificindicationsforfirst
trimesterultrasound)isbetween18weeksand20weeks6daysgestation(ACOG
LevelC)
ifultrasoundperformedinsecondtrimester,additionalultrasoundscreeningat>24
weeksgestationnotrecommendedasevidencedoesnotsupportitsuse
measurefundalheightateachprenatalvisitbeginningat20weeksgestationto
monitorfetalgrowth
offergeneticscreeningandinvasivediagnostictestingifnotdoneinfirsttrimester
prenatalcareinthirdtrimester
screenforgestationaldiabetesat2428weeksgestationduetopregnancyrelated
2/85
20/11/2015
DynaMed
hormonalchanges
tetanus,diptheria,andpertusiss(Tdap)vaccinerecommendedforallpregnantwomen
duringeachpregnancy,ideallybetween2736weeksgestation
performculturebasedscreeningforvaginalandrectalgroupBstreptococcal(GBS)
colonizationat3537weeksgestation,includinginwomenexpectedtoundergo
plannedcesareandelivery(CDCGradeA,LevelII)
assessfetalpresentationwithabdominalpalpation(Leopoldmaneuvers)beginningat
36weeksgestation
continuetomeasurebloodpressureforsignsofpreeclampsia
additionalconsiderations
antenatalfetalsurveillanceindicatedforcertainmaternalandpregnancyrelated
conditionsthatmayresultinfetalcompromisetechniquesinclude
maternalperceptionoffetalmovement
contractionstresstest(CST)
nonstresstest(NST)
biophysicalprofile(BPP)ormodifiedBPP
umbilicalarteryDopplervelocimetry
administerinfluenzavaccinetoallwomenwhoareorwillbepregnantduringinfluenza
season(OctoberMayinUnitedStates)
ConfirmingPregnancy
pregnancymaybeconfirmedbypregnancytest(urineorserum)andcombinationof
historyandphysicalexam(1,2)
patienthistoryofrecentamenorrhea,sexualactivity,lackoformisuseof
contraception,andpresenceofearlypregnancysymptoms(suchasnauseaandbreast
tenderness)mayincreaselikelihoodofpregnancy
pelvicexammayhelpidentifyenlargeduterussuggestingintrauterinepregnancy,
reproductivetractanomaliesandscreenforsexuallytransmittedinfections
detectingpregnancywithhumanchorionicgonadotropin(hCG)
hCGcanbedetectedinmaternalserum8daysafterconception
about10milliunits/mLcanbefoundinserumbetween910daysafterovulation
hcGlevelincreasesbyabout50%perdayaspregnancydevelops,reachingapeak
ofabout100,000milliunits/mLbyweek10
afterweek10,hCGlevelsdecreaseandremainstableat20,000milliunits/mLfor
remainderofpregnancy
hCGcanalsobedetectedinmaternalurine,withsimilarpatternsasfoundinmaternal
circulation
ReferenceGeburtshilfeFrauenheilkd2014Jul74(7):661fulltext
wholebloodisaseffectiveasurinefordetectingpregnancywithstandard
pointofcarepregnancytest(level1[likelyreliable]evidence)
basedondiagnosticcohortstudy
3/85
20/11/2015
DynaMed
633patients(meanage30years)requestingorrequiringapregnancytesthad
standardquantitativeserumtotalhCGassayusing2dropsofwholeblood(inplace
ofurineorserum)
502patientsalsohadstandardurinepregnancytest
pregnancyconfirmedifquantitativeserumhCG5milliunits/mL(reference
standard)
34%ofpatientswerepregnantbyreferencestandard
comparingdiagnosticperformanceofpregnancytestusingwholebloodvs.urine,no
significantdifferencesin
sensitivity(95.8%vs.95.3%)
specificity(100%vs.100%)
positivepredictivevalue(100%vs.100%)
negativepredictivevalue(97.9%vs.97.6%)
ReferenceJEmergMed2012Sep43(3):478
FirstResponsehomepregnancytest(manualordigital)appearsmore
effectivefordetectingpregnancyondayofmissedperiodthanotherhome
pregnancytests(level2[midlevel]evidence)
basedoncohortstudy
215womencollecteddailyurinesamplesinupto5menstrualcyclesuntilpregnancy
wasachieved,withcollectioncontinuinguntil6weeksafterpregnancyachieved
80ofthe137womenwhoachievedpregnancywithin5menstrualcycleshadurine
samplesevaluatedby6overthecounterpregnancytests
sensitivityofoverthecounterpregnancytestsfordetectingpregnancyontheday
ofmissedperiod
FirstResponseManual96%
FirstResponseGoldDigital96%
EPTManual53%
EPTDigital68%
ClearblueEasyManual67%
ClearblueEasyDigital51%
ReferenceClinChemLabMed2011Aug49(8):1317
positivehumanchorionicgonadotropin(hCG)mayoccurwithmenopause
basedon2cohortstudies
cohortof36perimenopausalorpostmenopausalwomenhadhCGlevelsevaluated
meanhCGlevel6.4units/Linperimenopausalwomenand11.6units/Lin
postmenopausalwomen
23of24womentreatedwithhighestrogenoralcontraceptivehadsuppression
ofhCG,suggestingpituitaryorigin
ReferenceAmJObstetGynecol2008Mar198(3):275.e1
cohortof28menopausalwomenwithdetectablehCGlevelswereevaluated
hCGlevelstypically<32units/L(32milliunits/mL)andresolvedwithhormone
4/85
20/11/2015
DynaMed
replacementtherapyfor2weeks
ReferenceNEnglJMed2007Mar15356(11):1184
falsepositiveurinepregnancytestreportedinpatientwhoreceivedinjectionofhCG
forovulationinduction(Lancet2004Jan31363(9406):362)
reviewofthehCGassayorpregnancytestcanbefoundinClinChemLabMed2012
Apr50(4):617
denialorlackofawarenessofpregnancyreportedin
1in475pregnancies(0.2%)at20weeksgestation
1in2,500pregnancies(0.04%)atterm
ReferenceJRSocMed2011Jul104(7):286fulltext
DeterminingGestationalAge
estimateddateofdelivery(EDD),alsocalledestimateddateofconfinement(EDC),is
calculatedbasedonthefirstdayofthelastmenstrualperiodplus280days (2)
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendationsfor
estimatingdateofdelivery
ultrasoundmeasurementoffetusinfirsttrimesterismostaccuratemethodto
establishandconfirmgestationalage
determinationofEDDbasedonlastmenstrualperiod(LMP)alonedoesnotaccount
forinaccuraterecallofLMP,irregularitiesincyclelength,orvariabilityoftimingof
ovulation
upto40%ofpregnantwomeninthefirsttrimesterreportedtohaveatleasta5
daydiscrepancybetweenultrasoundandLMPdatinginthefirsttrimester
accuratedeterminationofEDDmayreduceneedforpostterminductionsandlead
toearlierdetectionofmultiplegestationsandisrecommendedevenforwomenwith
certainLMP
determineEDDassoonasdatafromlastmenstrualperiod,firstaccurateultrasound,
orbothareavailable
inpregnanciesresultingfromassistedreproductivetechnology(ART)
useARTderivedgestationalagetodetermineestimateddateofdelivery(EDD)
determineEDDusingageofembryoanddateoftransferforpregnanciesresulting
frominvitrofertilization
ReferenceACOGcommitteeopiniononmethodsforestimatingduedate(Obstet
Gynecol2014Oct124(4):863)
AmericanCollegeofObstetriciansandGynecologists(ACOG)andAmericanInstitutefor
UltrasoundinMedicine(AIUM)recommendationsforultrasounddeterminationof
gestationalage
gestationalagemostaccuratelyidentifiedbyultrasoundmeasurementofcrownrump
lengthbetween10and136/7weeksgestation(ACOGLevelA)
variabilityinestimatesofgestationalageincreasewithincreasingdurationof
pregnancy
ifaccurateearlyscanisavailable,gestationalageshouldnotberedatedinlater
5/85
20/11/2015
DynaMed
trimesters
if<6weeksgestationorifembryoisnotvisible,assessgestationalsacdiameterto
determinegestationalage
gestationalsacshouldbevisibleasearlyas4weeksgestationandnolaterthan5
weeksgestation
meansacdiameter(averageof3measurementsofgestationalsac)canaccurately
estimategestationalage(meansacdiameter[mm]+30=gestationalageindays)
insecondorthirdtrimester,andifcrownrumplength>60mm,combinationof
methodsmaybemoreaccuratethananysinglemethodforestimatinggestationalage
methodsinclude
biparietaldiameter
measuredatlevelofthalamiandcavumseptipellucidiorcolumnsoffornix
(cerebellarhemispheresshouldnotbevisible)
measurementistakenfromouteredgeofproximalskulltoinneredgeofdistal
skull
headcircumference
measuredatsamelevelasbiparietaldiameteraroundouterperimeterof
calvarium
mostaccuratesinglemethodofestimatinggestationalagebetween14and22
weeksgestation(reportedtopredictgestationalagewithinabout3.4days)
headshapedoesnotaffectheadcircumferencemeasurement
somevariantsofnormalfetalheaddevelopment,suchasdolichocephalyor
brachycephaly,maymakeheadcircumferencemoreaccuratethanbiparietal
diameterforestimatinggestationalage
abdominalcircumferenceoraverageabdominaldiameter
measuredatskinlineontruetransverseviewatlevelofjunctionofumbilical
vein,portalsinus,andfetalstomachwhenvisible
maybeusedwithotherbiometricparameterstoestimatefetalweight
mayhelpdetectintrauterinegrowthrestriction(IUGR)ormacrosomia
femoraldiaphysislength
maybereliablyusedtoestimategestationalage>14weeksgestation
reportedaccuracyoffemurlengthforestimatinggestationalagerangesfrom
within1weekinsecondtrimestertowithin34weeksatterm
mostaccuratesinglemethodofestimatinggestationalageinthirdtrimester
longaxisoffemoralshaftmostaccuratelymeasuredwithbeamofinsonation
perpendiculartoshaft,excludingdistalfemoralepiphysis
ultrasoundvs.menstrualdatesforestimatinggestationalage
ultrasoundestablisheddatestakeprecedenceovermenstrualdateswhen
discrepancyis
>7daysinfirsttrimester
>10daysinsecondtrimester(upto20weeksgestation)
6/85
20/11/2015
DynaMed
ultrasoundestablisheddatesconfirmmenstrualdatesifgestationalageagreement
is
7daysofestimateobtainedbycrownrumplengthmeasurementinfirst
trimester
10daysofestimateobtainedbyaverageofmultiplefetalbiometric
measurementsinsecondtrimester(upto20weeksgestation)
References
AmericanCollegeofObstetriciansandGynecologists.ACOGPracticeBulletinNo.
101:Ultrasonographyinpregnancy.ObstetGynecol.2009Feb113(2Pt1):45161,
reaffirmed2014Aug
AmericanInstituteofUltrasoundinMedicine.AIUMpracticeguidelineforthe
performanceofobstetricultrasoundexaminations.JUltrasoundMed.2013
Jun32(6):1083101fulltext
AmericanCollegeofObstetriciansandGynecologists(ACOG)guidelinesforwhento
redateestimateddateofdelivery(EDD)perdiscrepancybetweenultrasounddatingand
lastmenstrualperiod,withultrasoundestablisheddatestakingprecedence
redateifdiscrepancy
>5daysat<9weeksgestation
>7daysfrom9to156/7weeksgestation
>21daysat28weeksgestation
ReferenceACOGcommitteeopiniononmethodsforestimatingduedate(Obstet
Gynecol2014Oct124(4):863)
seePrenatalultrasoundscreeningforadditionalinformation
TrimesterSpecificPrenatalCareandTesting
Generalconsiderations:
Numberofprenatalvisits:
mostwomenindevelopedcountrieshave712prenatalvisits (2)
AmericanAcademyofPediatrics(AAP)CommitteeonFetusandNewbornandAmerican
CollegeofObstetriciansandGynecologists(ACOG)CommitteeonObstetricPractice
recommendsprenatalvisits
monthlyupto28weeksgestation
every23weeksfrom2836weeksgestation
weeklyfrom36weeksgestationtodelivery
ReferenceAAP/ACOGguidelinesforperinatalcare,7thedition(AAP/ACOG2012)
reducednumberofprenatalvisitsassociatedwithincreasedperinatalmortality
comparedtostandardnumberofvisitsinlowriskwomeninlowandmiddle
incomecountries,butnotinlowriskwomeninhighincomecountries(level2
[midlevel]evidence)
7/85
20/11/2015
DynaMed
basedonCochranereviewoftrialswithoutblinding
systematicreviewof7randomizedorquasirandomizedtrialscomparingreduced
numberofprenatalvisitsvs.standardnumberofprenatalvisitsin60,724womenwith
lowriskpregnancies
numberofvisitsinstandardvs.reducedvisitgroups
notdefined(2trials)or14visits(1trial)vs.46visitsinlowandmiddleincome
countries
1214visitsvs.69visitsinhighincomecountries
reducednumberofprenatalvisitsassociatedwithincreasedperinatalmortalityinlow
andmiddleincomecountriesinanalysisof3trialswith51,323women
riskratio1.15(95%CI1.011.32)
NNH1484,762with2.1%perinatalmortalityinstandardcaregroup
nosignificantdifferenceinperinatalmortalityinanalysisof2trialswith5,108women
inhighincomecountries,butlowoverallrateofevents
ReferenceCochraneDatabaseSystRev2015Jul16(7):CD000934
mobilephoneinterventionmayincreaseattendanceatantenatalcarevisitsin
resourcelimitedsettings(level2[midlevel]evidence)
basedonclusterrandomizedtrialwithconfidenceintervalincludingdifferencesthatare
notclinicallymeaningful
24primaryhealthcarefacilitiesinZanzibar,Tanzaniawererandomizedtomobilephone
interventionvs.nophoneinterventionforpregnantwomen
mobilephoneinterventionconsistedoftextmessageremindersforantenatalvisits
twicepermonthuntilgestationalweek36,thentwiceperweek,plusmobilephone
credittoallowdirectcommunicationwithprimaryhealthcareproviderifneeded
(womenwhodidnotownmobilephonesreceivedvouchersbutnotreminders)
allwomenreceivedstandardmaternalcareandwerefollowedto42dayspost
partum
2,550pregnantwomenattendingfirstantenatalcarevisitinthesefacilitieswere
includedintrialregardlessofmobilephoneownership
3.4%ofwomendidnotcompletetrialandwereexcludedfromanalyses
4antenatalcarevisitsin44%withmobilephoneinterventionvs.31%without
intervention(adjustedoddratio2.4,95%CI1.035.6)
nosignificantdifferencesingestationalageatlastantenatalcarevisitorratesof
tetanusvaccinationorpreventivetreatmentformalaria
ReferenceBMCPregnancyChildbirth2014Jan1714:29fulltext
Elementsofprenatalvisitscontinuedthroughoutpregnancy:
determinebaselinebodymassindex(BMI)atinitialprenatalvisit,withweight
measurementatallsubsequentvisitstotrackweightgainduringpregnancy(2)
bloodpressuremeasurementgenerallysuggestedateveryprenatalvisittoassessfor
preeclampsia(2)
performauscultationoffetalheartrateateachvisitstartingbetween1012weeks
8/85
20/11/2015
DynaMed
gestationforconfirmationofviablefetus(noevidenceofotherclinicalorpredictivevalue)
(2)
performfundalheightmeasurement(incm)ateachprenatalvisitbeginningat20weeks
gestationtomonitorfetalgrowth(1,2)
maybeaffectedbyinterandintraobservervariability
typicallyconsiderednormalifwithin2cmofgestationalageinweeks(Cochrane
DatabaseSystRev2015Sep8(9):CD008136)
assesslowerextremitiesforedema(1,2)
definedas>1+pittingedemaafter12hoursbedrest,orweightgainof2.3kg(5
lbs)in1week
reportedtooccurin80%ofpregnantwomen
associatedwithlowsensitivityandspecificityfordiagnosingpreeclampsia
considerurinalysis (1,2)
routinedipstickanalysisisbecominglesscommonduetoevidenceshowinglimited
clinicalbenefit
traceglycosuriaisnotreliablefordetectionofgestationaldiabetes
visualdipsticktestingdoesnotappeartoeffectivelydiagnoseorexcludethreshold
levelproteinuriainpregnantwomen(level2[midlevel]evidence)
Firsttrimestercareandtesting:
determinebaselinebodymassindex(BMI)atinitialprenatalvisittotrackweightgain
duringpregnancy(2)
initialprenatalbloodtestsshouldinclude(1,2)
assessmentofmaternalbloodtypeandRhDantibodiesstatus
varicellaantibodytiterifnohistoryofmaternalvaricella(chickenpox)infection
completebloodcount(CBC)toscreenforanemia(treatwithironifindicated)
hemoglobinelectrophoresisinwomenofAfrican,SoutheastAsian,andMediterranean
descenttoscreenforhemoglobinopathies(RBCindicesfromCBCsufficientinallother
women)
HIVandsyphilis
thyroidstudies(indicatedinwomenatriskforthyroiddisease)
performabdominalandpelvicexamatfirstprenatalvisittoidentifyanygynecologic
abnormalitiesandtoscreenforsexuallytransmittedinfections (1,2)
offerpapsmearatrecommendedintervalsbasedonageandpapsmearhistory
routinepelvimetrynotrecommended
screenforasymptomaticbacteriuriawithurinecultureatfirstprenatalvisitorbetween
1116weeksgestation,andtreatifindicated(1)
considerpreconceptionorearlyprenatalscreeningforsexuallytransmittedinfections,
includinggonorrheaandchlamydia(1,2)
performriskassessmentatpreconceptionvisitorfirstprenatalvisit,including
assessmentof(1)
modifiableriskfactorsforpretermlabor
9/85
20/11/2015
DynaMed
workrelatedexposuretoinfectiousagentsorchemicals
modifiableriskfactorsforcontractinginfectiousdiseases(womenathighriskmay
requireadditionaltestingat28weeksgestation)
hereditarydisorders,suchashemoglobinopathies
useofprescriptionoroverthecountermedications
historyofphysical,emotional,orsexualabuse
alcoholuse
tobaccouse
substanceabuse,includingIVdruguse
personalorfamilyhistoryofgestationaldiabetesmellitus(GDM)ordiabetesmellitus
riskforpsychiatricdisorders
offergeneticscreeningandinvasivediagnostictestingtoallwomenpresentingfor
prenatalcarebefore20weeksgestation,regardlessofmaternalagecounselwomenon
differencebetweenscreeningandinvasivediagnostictesting(ACOGLevelB)(Obstet
Gynecol2007Jan109(1):217,reaffirmedJanuary2014)
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendationsforfirst
trimesterultrasound
performroutinefirsttrimesterultrasoundinallwomentoestimategestationalage
andevaluatesize,location,andnumberofgestationalsac(s)(ACOGLevelA)
diagnosticultrasoundsgenerallyconsideredsafeduringpregnancywhenused
appropriatelyandwhenmedicalinformationaboutpregnancyisneeded(ACOG
LevelA)
gestationalagemostaccuratelyidentifiedbycrownrumplengthbetween10weeks
and13weeks6daysgestation(ACOGLevelA)
definitivediagnosisofviableintrauterinepregnancyrequiresvisibleconfirmationof
intrauterinegestationalsaccontainingyolksacorembryo/fetusandvisualizationof
cardiacactivity
assessuterus,cervix,adnexa,andculdesacregiontoidentifylocationof
gestationalsacandfetalnumber
assesforcardiacactivitywith2dimensionalvideocliporMmodeimaging
determineamnionicityandchorionicityforallmultiplegestationswhenpossible
allpregnantwomenshouldbeofferedultrasoundscreeningforDownsyndromein
firsttrimesterandscreenforfetalaneuploidywhenrequested
limitedfirsttrimesterultrasoundmaybeusedtoestimateamnioticfluidvolumeas
needed(ACOGLevelB)
ReferenceACOGPracticeBulletinonultrasonographyinpregnancy(ObstetGynecol
2009Feb113(2Pt1):451,reaffirmed2014Aug)
seePrenatalultrasoundscreeningforadditionalinformation
Secondtrimestercareandtesting:
continuetomeasurebloodpressureforsignsofpreeclampsia(2)
measurefundalheightateachprenatalvisitbeginningat20weeksgestationtomonitor
10/85
20/11/2015
DynaMed
fetalgrowth(1,2)
offergeneticscreeningandinvasivediagnostictestingifnotdoneinfirsttrimester
(ObstetGynecol2007Jan109(1):217,reaffirmedJanuary2014)
routineantibioticprophylaxisduringsecondtrimesterisnotrecommendedforallwomen
forreducinginfectiousmorbidity(WHOStrongrecommendation,Verylowquality
evidence)(WHO2015PDF)
secondtrimesterultrasound
performsecondtrimesterultrasoundtoevaluatefetalanatomy,fetalpresentation,
amnioticfluidvolume,cardiacactivity,placentalposition,fetalbiometry,andfetal
number
timing
optimaltimingofsingleultrasoundexam(inabsenceofspecificindicationsforfirst
trimesterultrasound)isbetween18weeksand20weeks6daysgestation(ACOG
LevelC)
ifultrasoundperformedinsecondtrimester,additionalultrasoundscreeningat>24
weeksgestationnotrecommendedasevidencedoesnotsupportitsuse
imagingparametersformidtrimesterultrasound
documentfetalcardiacactivity,fetalnumber,andpresentation
performfetalanatomicsurvey
performgestationalageassessment(ifaccurateearlyscanisavailable,gestational
ageshouldnotberedatedinlatertrimesters)
estimateamnioticfluidlevels
assessplacentallocation,appearance,andrelationshiptointernalcervicalos
imageanddocumentnumberofvesselsinumbilicalcordandplacentalcord
insertionsite(whenpossible)
evaluatematernalanatomy
routinecervicallengthmeasurementinlowriskpregnanciesnotrecommended
ReferenceACOGPracticeBulletin101onultrasonographyinpregnancy(Obstet
Gynecol2009Feb113(2Pt1):451,reaffirmed2014Aug)
ultrasounddeterminationoffetalsexmaybemostreliablewhenfetalcrown
rumplengthis60mm(level2[midlevel]evidence)
basedoncohortstudy
122womenwithsingletonpregnancieshadtransabdominalultrasoundtodetermine
fetalsexat1214weeksgestationwithresultscomparedtophenotypicsexof
newbornafterdelivery
fetalcrownrumplength(CRL)wasmeasuredandgenitalareaoffetuswas
examinedinmidsagittalplane
accuracyofultrasoundsexassignmentaccordingtocrownrumplength
inmales
41%withCRL4549.9mm
11/85
20/11/2015
DynaMed
89%withCRL5054.9mm
99%withCRL5559.9mm
100%withCRL60mm
infemales
24%withCRL4549.9mm
67%withCRL5054.9mm
94%withCRL5559.9mm
100%withCRL60mm
ReferenceBiomedPapMedFacUnivPalackyOlomoucCzechRepub2012
Dec156(4):324PDF
inwomenathighriskforpretermbirth
considerserialevaluationofcervicallengthbeginningat16weeksgestationtoassess
riskforprimaryorrecurrentpretermbirth
cervicalsonographygenerallyperformedevery2weeksunlessclinicalconditions
indicatemorefrequentevaluation
ReferenceInstituteforClinicalSystemsImprovement(ICSI)guidelineon
routineprenatalcare(ICSI2012JulPDF),oratNationalGuidelineClearinghouse2012
Jul:38256
Thirdtrimestercareandtesting:
continuetomeasurebloodpressureforsignsofpreeclampsia(2)
screenforgestationaldiabetesat2428weeksgestationduetopregnancyrelated
hormonalchanges (1)
tetanus,diphtheria,andpertussis(Tdap)vaccinerecommendedforallpregnantwomen
duringeachpregnancy,ideallybetween2736weeksgestation(ObstetGynecol2013
Jun121(6):1411)
performculturebasedscreeningforvaginalandrectalgroupBstreptococcal(GBS)
colonizationat3537weeksgestation,includinginwomenexpectedtoundergoplanned
cesareandelivery(CDCGradeA,LevelII)(1,2)
routineantibioticprophylaxisduringthirdtrimesterisnotrecommendedforallwomenfor
reducinginfectiousmorbidity(WHOStrongrecommendation,Verylowqualityevidence)
(WHO2015PDF)
performabdominalpalpation(Leopoldmaneuvers)toassessfetalpresentationbeginning
at36weeksgestation(lessaccurateforfetalpresentationifperformedearlierin
pregnancy)(2)
Posttermcareandtesting:
beginningat41weeksgestation,fetalassessmenttypicallyincludestwiceweekly
nonstresstestingwithweeklyassessmentofamnioticfluidvolume(2)
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendationsfortiming
oflaborinductioninwomenwithposttermpregnancy(41weeksgestation)
laborinductionindicatedif
ultrasoundshowsamnioticfluidvolumeindex<5mLormaxverticalpocket<2cm
12/85
20/11/2015
DynaMed
(indicatingoligohydramnios)
nonreassuringresultsonnonstresstest,contractionstresstest,biophysicalprofile,
ormodifiedbiophysicalprofile
ifnormalresultsonantenatalfetalsurveillance
considerlaborinductionbetween410/7and420/7weeksgestation(ACOGLevel
B)
laborinductionrecommendedafter420/7andby426/7weeksgestationdueto
increasedperinatalmorbidityandmortalityassociatedwithposttermpregnancies
(ACOGLevelA)
ReferenceACOGPracticeBulletinonmanagementoflatetermandpostterm
pregnancies(ObstetGynecol2014Aug124(2Pt1):390)
seePosttermpregnancyforadditionalinformation
PrenatalScreeningParameters
AssessmentofmaternalbloodtypeandRhantibodystatus:
Screening:
screenallpregnantwomenforABObloodtypeandRhesus(Rh)Dantibodiesatfirst
prenatalvisit(1,2)
RhDincompatibilityreportedinupto10%ofpregnancies (1)
ifpreventativemeasuresnottaken,alloimmunizationreportedtooccurinabout(1)
0.7%1.8%ofwomenantenatally
8%17%ofwomenatdelivery
3%6%afterelectiveorspontaneousabortion
2%5%afteramniocentesis
riskforalloimmunizationreportedtobereducedtoabout0.2%inwomentreatedwith
Rh(D)immuneglobulin(RhoGam)(2)
costbenefitanalysisofimmunizingallRhDnegative,antiDantibodynegativewomen
withantiDimmuneglobulinat28weekscanbefoundinObstetGynecol2014
May123(5):938,editorialcanbefoundinObstetGynecol2014May123(5):919
newertechnologyallowsforscreeningoffetalbloodtypeat28weeksgestationusing
maternalplasma,followedbytreatmentforwomenwithpositiveorinconclusiveresults
onfetalbloodtype
goalofscreeningwouldbetoreducerateofunnecessaryantiRhDtreatmentinRhD
negativewomenfromabout40%(ifnoprenatalscreening)toabout6%(iftreating
womenwithpositiveorinconclusivetestresults)
screeningforfetalRhDgenotypeusingmaternalplasma
highthroughputautomaticRHDgenotypingoffetalDNAfrommaternal
plasmaisaccurate(level1[likelyreliable]evidence)
basedon2diagnosticcohortstudies
4,118maternalplasmasamplescollectedfromRhDnegativewomenatmean
gestationalage10weekswereanalyzedforRHDexon4usinghighthroughput
13/85
20/11/2015
DynaMed
automaticrobotictechnique
resultswerecomparedtoRhDphenotypesdeterminedfromcordblood
samplesin3,652deliveries
2,297(62.9%)cordsampleswereRhDpositive
of3,652maternalsamples
3,567(97.7%)predictedcorrectfetalRhDphenotype
70(1.9%)wereincorrect
15(0.4%)wereinconclusive
diagnosticperformanceofmaternalplasmatest
sensitivity97.6%
specificity98.9%
positivepredictivevalue99.3%
negativepredictivevalue96.1%
ReferenceObstetGynecol2012Aug120(2Pt1):227,editorialcanbefound
atObstetGynecol2012Aug120(2Pt1):219
1,997maternalplasmasamplescollectedfromRhDnegativewomenatmean
gestationalage27.9weekswereanalyzedforRHDgenotypewithhigh
throughputautomaticrobotictechnique
resultswerecomparedtoRhDphenotypesdeterminedfromcordblood
samplesin1,869deliveries
1,121(60%)cordbloodsampleswereRhDpositive
of1,869samples
1,788maternalplasmasamples(95.7%)predictedcorrectfetalRhD
phenotype
64tests(3.4%)wereinconclusive
17tests(0.9%)wereincorrect
diagnosticperformanceofmaternalplasmatest(withinconclusivetests
consideredpositive)
sensitivity99.7%
specificity94%
diagnosticperformance(withinconclusivetestsconsiderednegative)
sensitivity96.7%
specificity98%
clinicalutilitymightbetoreducerateofunnecessaryantiRhDtreatmentin
RhDnegativewomenfromabout40%(ifnoprenatalscreening)toabout6%
(iftreatingwomenwithpositiveorinconclusivetestresults)
ReferenceBMJ2008Apr12336(7648):816fulltext,editorialcanbefoundin
14/85
20/11/2015
DynaMed
BMJ2008Apr12336(7648):783fulltext,commentarycanbefoundinBMJ
2008Apr26336(7650):906fulltext
rateoffalsenegativeresultsonhighthroughputautomaticRHD
genotypingoffetalDNAfrommaternalplasmaappearshigherbefore11
weeksgestationthanlaterinpregnancy(level2[midlevel]evidence)
basedondiagnosticcohortstudywithoutindependentvalidation
4,913maternalplasmasamplescollectedfrom2,288RhDnegativewomenwere
analyzedforRHDgenotypewithhighthroughputautomaticrobotictechnique
upto4fetalgenotyperesultspermotherfromvaryinggestationalageswere
analyzed
gestationalageatsamplingrangedfrom5to35weeks(mean18.7weeks)
referencestandardwasRhDstatusfromcordbloodsamples
rateoffalseRhDnegativeresults
1.85%atgestationalage<11weeks
<0.1%atgestationalage11weeks
inconclusiveresultsin12.8%oftestsat<11weeksand5.7%oftestsat11
weeks
diagnosticperformanceofmaternalplasmatestfordiagnosisofRhDpositive
fetus(withinconclusivetestsconsideredpositive)
gestationalage<11weeks,sensitivity96.85%andspecificity94.4%
gestationalage1113weeks,sensitivity99.83%andspecificity95.25%
gestationalage24weeks,sensitivity100%andspecificity95.74%
ReferenceBMJ2014Sep4349:g5243fulltext
seeHemolyticdiseaseofthefetusandnewborn(HDFN)foradditionalinformation
Rho(D)immuneglobulinprophylaxis:
RoyalCollegeofObstetriciansandGynaecologists(RCOG)recommendationsforRho(D)
immuneglobulinadministrationinRhDnegative,nonsensitizedwomen
offerroutineprenatalprophylaxistoallRhDnegative,nonsensitizedwomen(RCOG
GradeB)
priortoadministration,performroutine28weekantibodyscreening(RCOGGradeC)
regimenoptionsinclude2dosesof500units(100mcg)at28and34weeks
gestationorsingledoseof1,500units(300mcg)at28weeksgestation
decisiontypicallymadebylocalcareprovider
nopublishedstudiescomparingefficacybetween2regimens
noevidenceofseriousadverseeventsformotherorbaby,otherthanslightriskof
bloodborneinfection(RCOGGradeB)
inpatientswhodeclineroutineprophylaxis,performantibodyscreeningatbooking
andat28weeksgestationtoidentifypossiblesensitization(RCOGGradeC)
prophylaxisafterpotentiallysensitizingeventduringpregnancy
15/85
20/11/2015
DynaMed
provideinadditiontoanyRho(D)immuneglobulinalreadyreceived
giveRho(D)immuneglobulinassoonaspossibleandalwayswithin72hoursafter
potentiallysensitizingevent(RCOGGradeD)
stillgivethedoseevenifunabletogivewithin72hours,asanydosegiven
within10daysmaystilloffersomeprotection
besttoadministerintodeltoidmuscle
administerIVorsubcutaneouslyinwomenwithbleedingdisorder
recommendedregimen
250unitsaftersensitizingeventoccurring19+6weeksgestation(RCOG
GradeD)
500unitsaftersensitizingeventoccurring20+0weeksgestation,additional
dosemayberequirediffetalmaternalhemorrhage>4mLredcells(RCOG
GradeD)
administeratminimumof6weeklyintervalsifrecurrentvaginalbleedingoccurs
after20+0weeksgestation(RCOGGradeD)
sensitizingeventsinclude
invasiveprenataldiagnostictests(suchasamniocentesis,chorionicvillus
sampling,cordocentesis,intrauterinetransfusion)
otherintrauterineprocedures(suchasshuntinsertionandembryoreduction)
antepartumhemorrhage
attemptsatexternalcephalicversionoffetus
anyabdominaltrauma
fetaldeath
postnatalprophylaxis
giveRho(D)immuneglobulin500units(100mcg)within72hoursofdeliveryof
RhDpositiveinfant(RCOGGradeA/B)
performKleihauertesttoidentifyfetalmaternalhemorrhage>4mLredcells,which
indicatesneedforadditionalRho(D)immuneglobulin(RCOGGradeC/D)
giveifpregnancyisnonviableandnobloodsamplecanbeobtainedfromfetus
(RCOGGradeD)
otherconsiderations
formiscarriage
giveRho(D)immuneglobulinifspontaneousmiscarriageat12+0weeks
gestationorifsurgicalevacuationoftheuterus,regardlessofgestation(RCOG
GradeD)
considergivingRho(D)immuneglobulinifmedicalevacuationoftheuterus,
regardlessofgestation(RCOGGradeD)
notrequiredforspontaneousmiscarriageat<12+0weeksgestationunless
patienthasinstrumentationoftheuterus(RCOGGradeD)
antiDadministrationafterspontaneousmiscarriageforpreventingRhesus
alloimmunization(CochraneDatabaseSystRev2013Mar283:CD009617)
16/85
20/11/2015
DynaMed
forthreatenedmiscarriage
giveRho(D)immuneglobulinifthreatenedmiscarriageat>12+0weeks
gestation,andadministerat6weeklyintervalsifbleedingcontinuesintermittently
after12+0weeksgestation(RCOGGradeD)
considergivingRho(D)immuneglobulinifheavyorrepeatedbleedingor
associatedabdominalpainwhenapproaching12+0weeksgestation(RCOGGrade
D)
forectopicpregnancy,giveRho(D)immuneglobulin,regardlessofmanagement
(RCOGGradeD)
formedicalorsurgicaltherapeuticabortion,giveRho(D)immuneglobulin,regardless
ofgestationalage(RCOGGradeD)
ReferenceRoyalCollegeofObstetricianandGynaecologistsGreentopGuideline22
TheUseofAntiDImmunoglobulinforRhesusDProphylaxis2011MarPDForat
NationalGuidelineClearinghouse2012May14:34964
seeHemolyticdiseaseofthefetusandnewborn(HDFN)foradditionalinformation
Screeningforirondeficiency:
performhemoglobinassessmenttoscreenforirondeficiencyanemiainallpregnant
womenatfirstprenatalvisit,andgiveelementalironifindicated(1,2)
ifrepeathemoglobinassessmentat1monthisstilllowafterinitiatingirontherapy,
assessserumferritinlevels (1)
serumferritinappearstobemosteffectivemethodfordiagnosingirondeficiencyin
anemicpatients
serumferritin<12mcg/Lindicatesirondeficiencyanemia
assessforotherconditions,includingmalabsorption,ongoingbloodloss,thalassemia,
orotherchronicdiseasein(2)
womenwithanemianotduetoirondeficiency
womenwithirondeficiencyanemiawhohavenotrespondedtoiron
supplementationwithin46weeks
anemiainpregnancymaynotbeassociatedwithirondeficiency
basedoncohortstudy
182consecutivewomenenteringprenatalcarewereevaluated
173(95%)hadhemoglobindata
among38women(22%)withanemia(definedashemoglobin<11g/dL[110g/L])
54%hadanemiarelatedtoirondeficiency,definedasferritin<12ng/dL(0.27
pmol/L)
46%hadanemianotrelatedtoirondeficiency
ReferenceJFamPract2000Sep49(9):829
EBSCOhostFullTextfulltext
treatment
givecourseofelementaliron30mg/dayorallyin23equallyspaceddosesinwomen
with(1)
hemoglobin<11g/dLinfirstorthirdtrimester
17/85
20/11/2015
DynaMed
hemoglobin<10.5g/dLinsecondtrimester
supplementalironisavailableinferrousandferricforms (1)
ferrousironsaltsconsiderbestabsorbedformofironsupplementation
ferrousironsaltsincludeferrousfumarate,ferroussulfate,andferrousgluconate
consideradditionalsupplementationwithcopperandzincinwomenhavingiron
supplementation(1)
encouragepregnantwomentodrinkwaterororangejuice,andeatfoodshighin
iron(1)
advisewomenthatdrinkingmilk,coffee,orteawithmealsreducesironabsorption(1)
insufficientevidenceforroutineironsupplementationinpregnancy(1)
ironsupplementationreportedtoincreasehemoglobinlevelsinpregnant
womenwithirondeficiencyanemia(level3[lackingdirect]evidence)
basedonCochranereviewoftrialswithoutclinicaloutcomes
systematicreviewof23randomizedtrialsevaluatingirontreatmentforanemia
(definedashemoglobin<11g/dL)attributedtoirondeficiencyin3,198pregnant
women
manytrialsconductedinlowincomecountries
metaanalysescomplicatedbyheterogeneityindrugs,doses,androutesof
administration
oraliron(comparedtoplacebo)associatedwith
lowerincidenceofanemiaduringsecondtrimester(32%vs.84%,p<0.0001,
NNT2)in1trialwith125women
higherhemoglobinlevels(meandifference[MD]1.34g/dL,95%CI0.272.42
g/dL)inanalysisof2trialswith215women,analysislimitedbysignificant
heterogeneity
comparedtooraliron
intramuscularironassociatedwithsignificantlyhigherhemoglobinand/or
hematocritlevelsin4trialswith571women
IVironassociatedwithhighermeanhemoglobinlevelsat4weeks(MD0.44
g/dL,95%CI0.050.82g/dL)inanalysisof3trialswith167patients
insufficientevidencetoevaluateclinicallyrelevantoutcomesoradverseeffects
ReferenceCochraneDatabaseSystRev2011Oct5(10):CD003094
Screeningforinfectiousdiseases:
GroupBstreptococcal(GBS)colonization:
CentersforDiseaseControlandPrevention(CDC)2010guidelinesonscreeningfor
perinatalgroupBStreptococcus(GBS)disease(endorsedbyAmericanCollegeof
ObstetriciansandGynecologists[ACOG]andAmericanAcademyofPediatrics[AAP])
provideuniversalprenatalculturebasedscreeningforvaginalandrectalGBS
colonizationat3537weeksgestation,includingwomenexpectedtoundergoplanned
cesareandelivery(CDCGradeA,LevelII)
specimencollectionandprocessing
18/85
20/11/2015
DynaMed
singlecombinedvaginalrectalspecimen(CDCGradeA,LevelII)
swablowervagina,followedbyrectumwithsameswabor2differentswabs
cervical,perianal,orperinealspecimensnotacceptable
speculumshouldnotbeused
susceptibilitytestingofGBSisolates
performantimicrobialsusceptibilitytestingonisolatesfromwomenallergicto
penicillinathighriskforanaphylaxis(CDCGradeA,LevelII)
performinducibleclindamycinresistancetestingonisolatesfromwomenallergic
topenicillinathighriskforanaphylaxisthataresusceptibletoclindamycinand
resistanttoerythromycin(CDCGradeC,LevelIII)
ReferenceMMWRRecommRep2010Nov1959(RR10):1fulltextoratNational
GuidelineClearinghouse2011Mar28:24591
summary(Overviewof2010Guidelines)canbefoundatCDC2013Sep9
RoyalCollegeofObstetriciansandGynaecologists(RCOG)recommendationsonantenatal
screeningforpreventionofearlyonsetneonatalgroupBstreptococcal(GBS)disease
routineculturebasedscreeningforantenatalvaginalrectalGBScolonizationisnot
recommended(RCOGGradeD,Level4)
insufficientevidencetorecommendscreeningforGBSorintrapartumantibiotic
prophylaxisinwomenwithhistoryofGBScolonizationinpreviouspregnancy(RCOG
GradeD,Level3)
ReferenceRCOGguidelineonpreventionofearlyonsetneonatalgroupB
streptococcaldisease(RCOG2012JulPDF)
seePreventionofgroupBstreptococcalinfectioninthenewbornforadditional
information
MaternalGBStestingconsiderations:
vaginalperianalcultureisaseffectiveasvaginalrectalculturefordetectionof
GBSandassociatedwithlessdiscomfort(level1[likelyreliable]evidence)
basedon2diagnosticcohortstudies
cohortof193pregnantwomenat3537weeksgestationhadvaginalperianalculture
followedbyvaginalrectalcultureforGBSandevaluatedforpainlevelwitheach
collectionmethod
29%hadGBSinfectionbyvaginalrectalculture(referencestandard)
fordetectionofGBS,vaginalperianalculturehad
sensitivity91.1%
specificity98.5%
vaginalperianalcollectionassociatedwithlowermeanpainscore(1.2vs.3.4,p<
0.001)andwasratedaslessuncomfortablethanvaginalrectalcollectionby68%of
women
ReferenceObstetGynecol2011Aug118(2Pt1):313
19/85
20/11/2015
DynaMed
cohortof200pregnantwomeninthirdtrimesterhadserialspecimensoflowerthirdof
vagina,perianalskin,andrectum
36%ofwomenhadpositiveGBSculturefromatleast1site
GBSdetectedin34%ofwomenhavingvaginalperianalculturecomparedto
34%ofwomenhavingvaginalrectalcultures(notsignificant)
28%ofwomenhavingvaginalculturealone(p=0.001)
24%ofwomenhavingperianalculturealone(p=0.001)
25%ofwomenhavingrectalculturealone(p=0.0005)
ReferenceObstetGynecol2004Nov104(5):1058,summarycanbefoundinAm
FamPhysician2005Sep1572(6):1116
patientcollectedandphysiciancollectedspecimensappeartohavesimilar
efficacyfordetectionofGBScolonization(level2[midlevel]evidence)
basedon2diagnosticcohortstudieswithoutindependentreferencestandard
cohortof800specimensfromprimarilyHispanicandlowersocioeconomicwomenwere
evaluated
36.6%specimenswerepatientcollected
GBSdetectedin13.31%ofpatientcollectedspecimensvs.10.65%ofphysician
collectedspecimens(notsignificant)
ReferenceJAmBoardFamMed2009MarApr22(2):136fulltext
cohortof250pregnantwomenselfperformedananogenitalswabbeforeoraftera
physicianperformedanogenitalswabinalternatingfashion
16.8%hadpositiveGBScultures
nosignificantdifferencebetweenswabresultscollectedbyphysiciansorpatients
58%ofpatientspreferredselfcollection
ReferenceJAmBoardFamPract2000MarApr13(2):107,commentarycanbe
foundinJAmBoardFamPract2000SepOct13(5):385
useofsurgicallubricantduringpelvicexamtocollectspecimensmaybe
associatedwithdecreaseddetectionofGBS(level2[midlevel]evidence)
basedonprospectivecohortstudy
168obstetricpatientshadGBSscreeningspecimenscollectedbeforeandafterpelvic
examwithSurgilubesurgicallubricant
11.9%ofpatientshadpositiveGBStestpriortopelvicexamwithlubricant
6%ofpatientshadpositiveGBStestfollowingpelvicexamwithlubricant
GBSscreeninghad50%sensitivityfordetectingGBSafterpelvicexaminationwith
surgicallubricant
ReferenceAmJObstetGynecol2010Mar202(3):276e1
DynaMedcommentaryCDC2010recommendsagainstuseofspeculum(pelvic
exam)forcollectionofGBSculture
polymerasechainreaction(PCR)forgroupBstreptococcus(GBS)
polymerasechainreaction(PCR)maybemostaccuratetestforrapid
intrapartumGBStesting(level2[midlevel]evidence)
20/85
20/11/2015
DynaMed
basedonsystematicreviewofstudieswithmethodologiclimitations
systematicreviewof23studiesofGBStestsofpregnantwomeninlaborusing
laboratorycultureasreferencestandard
only4studiesusedconsecutiverecruitment,only4studiesusedblindedtest
assessment,only2studies(1ofPCR,1ofopticalimmunoassay)metbothofthese
qualitycriteria
PCRevaluatedin2studiesaccurateandavailablein40minutesforrealtimePCR
sensitivitiesrangedfrom94%to100%
specificitiesrangedfrom90%to100%
pooledpositivelikelihoodratio38.8
poolednegativelikelihoodratio0.06
PCRtook40minutesforrealtimePCRand100minutesforconventionalPCR
fordetailson5othertestingmethods
opticalimmunoassayevaluatedin5studieslowersensitivitybutavailablein30
minutes
pooledpositivelikelihoodratio16
enzymeimmunoassayevaluatedin8studieslowersensitivitybutavailablein5
10minutes
latexagglutinationevaluatedin10studiespossiblyaccuratebuttakes7085
minutes
pooledpositivelikelihoodratio10.37andpoolednegativelikelihoodratio0.38
forstudiesusingselectiveenrichmentcultureasreferencestandard
(consideredappropriatereferencestandard)
pooledpositivelikelihoodratio83.18andpoolednegativelikelihoodratio0.43
forstudiesusingdirectcultureasreferencestandard(considered
inappropriatereferencestandard)
DNAhybridizationevaluatedin2studies
DNAhybridizationtook601,440minutes,soconsideredimpracticalforrapid
testing
Islamstarchmediumevaluatedin2studies
21/85
20/11/2015
DynaMed
Islamstarchmediumtook1201,400minutes,soconsideredimpracticalfor
rapidtesting
ReferencePediatrics2006Apr117(4):1055fulltext
intrapartumGBSrealtimePCRassayismoreaccuratethanantenatalGBS
culturefordetectionofGBS(level1[likelyreliable]evidence)
559women18yearsoldinlaborwithdocumentedprenatalGBScultureresults
hadrectovaginalspecimenscollectedandtestedwithCepheidXpertGBSrealtime
PCRassayandwithGBSculture
23.8%ofwomenwerepositiveforGBScolonizationbyintrapartumculture
(referencestandard)
fordetectionofGBSonintrapartumculture
intrapartumGBSPCRassayhad
sensitivity90.8%
specificity97.6%
positivepredictivevalue(PPV)92.3%
negativepredictivevalue(NPV)97.1%
prenatalGBSculturehad
sensitivity69.2%
specificity96%
PPV84.4%
NPV90.9%
ReferenceAmJObstetGynecol2011Oct205(4):372.e1fulltext
Varicella(chickenpox):
assessmaternalvaricella(chickenpox)historyatfirstprenatalvisit,andperform
serologicaltestinginwomenwithnegativehistoryforvaricellainfection(1,2)
forwomenwhotestnegativeforimmunoglobulinG
advisewomentoavoidvaricellaexposureduringpregnancy(2)
offervaricellavaccinationpostpartum(recommendedforalladultsifseronegativefor
immunoglobulinG)(2)
varicellavaccination(livevaccine)notrecommendedduringpregnancy(1)
ifavailable,considervaricellazosterimmuneglobulintherapyinwomenwhohave
significantexposuretovaricellainpregnancy(2)
Sexuallytransmittedinfections:
considerpreconceptionorprenatalscreening(atfirstprenatalvisit)for(1,2)
hepatitisBinallwomen
universalscreeningforhepatitisBsurfaceantigen(HbsAg)recommendedatfirst
22/85
20/11/2015
DynaMed
prenatalvisit
additionalscreeninglaterinpregnancyrecommendedinwomenathighrisk,
characterizedby
1sexpartnerinprevious6months
evaluationortreatmentforsexuallytransmittedinfection(s)
currentorrecentIVdruguse
HbsAgpositivepartner
testingforhepatitisBeantigenandviralloadinhepatitisBpositive
pregnantwomenmighthelppreventperinataltransmission
basedonMarkovdecisionmodelanalysisconstructedfora2010birthcohortof4
millionneonates
effectivenessoftestinghepatitisBpositivepregnantwomenforhepatitisBe
antigen(HBeAg)orhepatitisBvirus(HBV)DNA(viralload)andadministering
maternalantiviralprophylaxiswhenappropriatewascomparedwithcurrent
recommendation(hepatitisBsurfaceantigen[HBsAg])screeningforallpregnant
women
maternalantiviralprophylaxisgivenfrom28weeksgestationthrough4weeks
postpartumwhenHBeAgpositiveorHBVload10copies/mL
allneonatesborntoHBsAgpositivewomenreceivedrecommendedactive
passiveimmunoprophylaxis
comparedwithcurrentrecommendation
HBeAgtestingstrategyassociatedwithsavingsof$3.3millionand3,080
qualityadjustedlifeyears(QALYs)andpreventionof486chronicHBV
infections
HBVloadtestingstrategyassociatedwithsavingsof$3millionand2,080
QALYsandpreventionof324chronicinfections
ReferenceObstetGynecol2014May123(5):929,editorialcanbefoundin
ObstetGynecol2014May123(5):919
HIVinfectioninallwomen
patientsmayoptoutofscreening
considerrepeatscreeninginthirdtrimester
antiretroviraltherapyreducesriskforperinatalHIVtransmission
syphilisinallwomen
consideruniversalrapidplasmareaginorVenerealDiseaseResearchLaboratories
testing
considerrepeatscreeningat28weeksgestation
treatmentearlyinpregnancyreducesriskforcongenitalsyphilis
samedaysyphilisscreeningandtreatmentinpregnantwomenmayreduce
incidenceofcongenitalsyphilisbutmayhavesimilarriskofperinatal
mortalitycomparedtoconventionaltesting(level2[midlevel]evidence)
basedonCochranereviewoftrialswithunclearblinding
23/85
20/11/2015
DynaMed
systematicreviewof2randomizedtrialsevaluatingantenatalsyphilisscreeningin
8,493pregnantwomen
bothtrialsevaluatedsamedaytestingandtreatment,conductedinMongoliaand
SouthAfrica
comparingsamedaytestingandtreatmenttoconventionaltestingmethods
congenitalsyphilisin0.03%vs.0.42%(p<0.05,NNT257)in1trialwith
7,184infants
perinatalmortality3.3%vs.5.1%(notsignificant)insubgroupof706infants
whosemothershadsyphilis(1trialwith7,618women)
ReferenceCochraneDatabaseSystRev2014Oct29(10):CD010385
chlamydia
inwomenaged>25yearsathighriskforinfection
inwomenaged25years,regardlessofriskstatus
considerrepeatscreeninginsecondsemesterinwomenathighriskforinfection
treatmentreducesriskforadversepregnancyandneonataloutcomes
gonorrhea
inwomenathighriskforsexuallytransmittedinfection
treatmentreducesriskforadversepregnancyoutcomes
hepatitisCinwomenathighriskforhepatitisCinfection,includingwomenwith
currentorrecentIVdruguse
historyofbloodtransfusionororgantransplantbefore1992
Asymptomaticbacteriuria:
screenforasymptomaticbacteriuriawithurineculturebetween1116weeksgestation,
andtreatifindicated(1,2)
InfectiousDiseasesSocietyofAmerica(IDSA)screeningguidelinesforasymptomatic
bacteriuriainpregnantwomen
screenbyurinecultureatleastonceearlyinpregnancy,andtreatifpositiveculture
ifpositivescreeningculture,screenperiodicallyforrecurrentbacteriuriaaftertreatment
norecommendationfororagainstscreeningculturenegativewomenlaterin
pregnancy
ReferenceClinInfectDis2005Mar140(5):643
EBSCOhostFullTextfulltext,
correctioncanbefoundinClinInfectDis2005May1540(10):1556,summarycanbe
foundinAmFamPhysician2005Sep1572(6):1128
UnitedStatesPreventiveServicesTaskForcerecommendationsonscreeningfor
asymptomaticbacteriuria
UnitedStatesPreventiveServicesTaskForce(USPSTF)stronglyrecommends
screeningallpregnantwomenforasymptomaticbacteriuriausingurinecultureat12
16weeksgestation(USPSTFGradeA)
ReferenceAnnInternMed2008Jul1149(1):43
EBSCOhostFullTextfulltext,
supportingsystematicreviewcanbefoundinAnnInternMed2008Jul1149(1):W20
EBSCOhostFullTextfulltext,editorialcanbefoundinAnnInternMed2008Jul
24/85
20/11/2015
DynaMed
1149(1):I37
EBSCOhostFullText,summarycanbefoundinAmFamPhysician
2010Feb1581(4):505
EBSCOhostFullText
reagentteststrips(suchasdipstick)maynotbeadequateforscreening
pregnantwomenforasymptomaticbacteriuria
basedonprospectivecaseseries
893pregnantwomenscreenedatfirstprenatalvisit(womenonantibioticsorwith
urinarysymptomsexcluded)
reagentteststripforblood,protein,nitrite,andleukocyteesterasewascomparedto
microscopyandculture
usinganyof4criteriahadonly33%sensitivity,91%specificity,18%positive
predictivevalue,and96%negativepredictivevalueforbacteriuria
usingnitritetestalonehad19%sensitivity,99.5%specificity,69%positivepredictive
value,and95.6%negativepredictivevalue
ReferenceBMJ1998Feb7316(7129):435fulltext
duringpregnancydipslideculturetechniqueassociatedwithmoreaccurate
detectionofasymptomaticbacteriuriacomparedwithnitrateandleukocyte
esterasedipslides
basedonancillarystudywithinlargertrialcomparingsingledayvs.7daytreatmentof
asymptomaticbacteriuria
3,048pregnantwomenseekingroutineprenatalcareprovidedcleancatchmidstream
urinesamples
dipslideisplasticpaddlecoatedwithagarattachedtoplasticcapthatscrewsonto
sterileplasticvial
15%prevalenceofasymptomaticbacteriuria
fordipslidetest
positivelikelihoodratio225(95%CI113449)
negativelikelihoodratio0.02(95%CI0.010.05)
fornitrateandleukocyteesterasedipslides(1orbothreadpositive)
positivelikelihoodratio6.95(95%CI5.88.33)
negativelikelihoodratio0.5(95%CI0.450.57)
ReferenceObstetGynecol2009Feb113(2Pt1):346,commentarycanbefoundin
ObstetGynecol2009Jul114(1):175
seeAsymptomaticbacteriuriaforadditionalinformation
Rubella:
rubellascreeningmosteffectivewhenperformedpriortoconception,whenvaccinationis
anoption(1,2)
inwomenwhoarenotimmune,offervaccinationinpostpartumperiodtoprevent
congenitalrubellasyndromeinsubsequentpregnancies (1,2)
rubellavaccinationnotrecommendedduringpregnancybutmaybegiventowomenwho
arebreastfeeding(1,2)
about32%ofpregnantwomenmaybesusceptibletorubella,measles,or
25/85
20/11/2015
DynaMed
mumps
basedoncohortstudy
973pregnantwomenhadrubella,rubeola,andmumsantibodytitresmeasures
317(32.6%)weresusceptibleto1infectiousviruses
91(9.4%)weresusceptibletorubella
161(16.5%)weresusceptibletomeasles
159(16.3%)weresusceptibletomumps
17(1.7%)weresusceptibletoall3viruses
ReferenceObstetGynecol2005Aug106(2):295,commentarycanbefoundinAm
FamPhysician2006Mar173(5):907
Bacterialvaginosis:
considerscreeningforbacterialvaginosisinwomenwithhistoryofpretermlabor(1)
routinescreeningforbacterialvaginosisnotrecommendedinpregnancy(1,2)
screeningGramstainofvaginalsmearforasymptomaticvaginalinfectionin
secondtrimestermayreduceriskofpretermdelivery(level2[midlevel]
evidence)
basedonrandomizedtrialwithunclearallocationconcealment
4,429pregnantwomeninearlysecondtrimester(1520weeksgestation)with
singletonpregnancyandnovaginalsymptomshadGramstainscreeningfor
asymptomaticvaginalinfection(bacterialvaginosis,candidiasisortrichomoniasis)
obstetriciansrandomizedtoreceiveGramstaintestresultsvs.notreceivetestresults
abnormaltestsledtotreatmentandrepeattestingat2427weeksinintervention
group
21%hadabnormalvaginalflora,including8.5%withbacterialvaginosisand14%with
Candida
outcomedataavailablefor4,155women(94%)
pretermdeliverybefore37weeksgestationin3%withobstetricianknowledgeofGram
stainresultsvs.5.3%withnoknowledgeofGramstainresults(p=0.0001,NNT44)
ReferenceBMJ2004Aug14329(7462):371fulltext,editorialcanbefoundinBMJ
2004Aug14329(7462):374fulltext
noadditionaltrialsfoundinCochranereviewevaluatingantenatallowergenitaltract
infectionscreeningandtreatmentprogramsforpreventingpretermdelivery(Cochrane
DatabaseSystRev2015Feb1(2):CD006178)
screeningforbacterialvaginosis
UnitedStatesPreventiveServicesTaskForce(USPSTF)recommendationsfor
screeningforbacterialvaginosis(BV)inpregnancy
insufficientevidencetorecommendfororagainstscreeningforBVinpregnant
womenathighriskforpretermdelivery(gradeIrecommendation)
goodevidencetorecommendagainstscreeningforBVinasymptomaticpregnant
womenatlowriskforpretermdelivery(gradeDrecommendation)
ReferenceAnnInternMed2008Feb5148(3):214
EBSCOhostFullText,
26/85
20/11/2015
DynaMed
supportingsystematicreviewcanbefoundinAnnInternMed2008Feb
5148(3):220
EBSCOhostFullText
clindamycingivenbefore20weeksgestationmayreduceriskforpreterm
birthinwomenwithbacterialvaginosis(level2[midlevel]evidence)
basedonsystematicreviewwithinadequateassessmentoftrialquality
systematicreviewof12randomizedtrialsevaluatingantibioticsinpregnantwomen
withsymptomaticorasymptomaticbacterialvaginosis(BV)orTrichomonasvaginalis
eligiblewomenwereinsecondorthirdtrimesterofpregnancy,hadintact
membranes,andwerenotinlabor
qualitycriteriaofreviewwaspublicationinEnglish,dropoutrates20%andusable
outcomesallocationconcealmentnotevaluated
intrialsofwomenwithbacterialvaginosis,comparingantibiotics(metronidazoleor
clindamycin)vs.control
antibioticsreducedriskofpersistentinfectioninanalysisof5trialswith3,088
patients
relativerisk(RR)0.32(95%CI0.20.52)
NNT24for61.2%persistentinfectionrateincontrolgroup
nosignificantdifferencesinratesofpretermbirth,lowbirthweight,neonatal
intensivecareunit(ICU)admission,perinataldeath,orpretermprelaborrupture
ofmembranes
in2trialsofwomenwithbacterialvaginosis,earlytreatmentwithclindamycin
associatedwithsignificantreductioninpretermbirth
RR0.41(95%CI0.180.91,p=0.03)in1trialof409womenreceiving
clindamycinintravaginallyfor3nightsat1320weeksgestation
RR0.39(95%CI0.20.76,p=0.005)in1trialof485womentreatedwith
clindamycinorallyfor5daysat1216weeksgestation
in1trialof617womenwithasymptomaticTrichomonasvaginalis,metronidazole
associatedwithincreasedriskofpretermbirth<37weeks(RR1.78,95%CI1.19
2.66)
ReferenceObstetGynecol2005Apr105(4):857
seeBacterialvaginosisforadditionalinformation
Otherinfections:
considerantibodytestingforparvovirusB19inwomenwithsignificantexposureduring
pregnancy(2)
selectivescreeningforcytomegalovirusmaybeindicatedforhighriskpatients,including(1)
daycareworkers
neonatalintensivecareunit(NICU)nurses
adolescentswithmultiplepartnersorhistoryofsexuallytransmitteddisease
routinescreeningnotrecommendedfor(1,2)
toxoplasmosis
cytomegalovirus
27/85
20/11/2015
DynaMed
parvovirus
considerscreeningforhelminthsinpregnantwomenfromcountrieswherehelminthiasisis
endemic,suchasthetropicsorSubSaharanAfrica
asymptomatichelminthinfectionreportedtobecommoninpregnantwomenwhodrink
untreatedwaterincrosssectionalstudyinKenya(PLoSNeglTropDis
20093(1):e370fulltext)
antihelminthicsmaynotreducematernalanemiainthirdtrimesterof
pregnancy(level2[midlevel]evidence)
basedonCochranereviewlimitedbyheterogeneity
systematicreviewof4randomizedtrialscomparingantihelminthicsvs.placeboorno
treatmentin4,265womeninsecondorthirdtrimesterofpregnancy
alltrialsinitiatedantihelminthictreatmentduringsecondtrimesterofpregnancy
comparingsingledosealbendazoleormebendazoleplusdailyironsupplementation
todailyironsupplementationalone,nosignificantdifferencesin
maternalanemiainthirdtrimesterofpregnancyinanalysisof3trialswith1,290
women,resultslimitedbysignificantheterogeneity
pretermbirthinanalysisof2trialswith1,318women
perinatalmortalityin1trialwith996infants
comparingsingledosealbendazole,praziquantel,orbothtoplacebo(noiron
supplementationineithergroup),nosignificantdifferencesin
maternalanemiainthirdtrimesterofpregnancyinanalysisof2trialswith1,976
women
lowbirthweightin1trialwith1,964infants
perinatalmortalityin1trialwith2,389infants
ReferenceCochraneDatabaseSystRev2015Jun18(6):CD005547
treatmentwithantihelminthicsafterfirsttrimesterofpregnancymaynot
improvematernalorperinataloutcomes(level2[midlevel]evidence)
basedonrandomizedtrialwithoutintentiontotreatanalysis
2,507womeninUgandainsecondorthirdtrimesterofpregnancyrandomizedto
1of4groups
albendazole440mgplusplacebo
placebopluspraziquantel40mg/kg
albendazole440mgpluspraziquantel40mg/kg
placeboplusplacebo
68%hadhelminths,45%hadhookworm,18%hadSchistosomamansoni
infectionand40%wereanemic(hemoglobin<11.2g/dL)atbaseline
nosignificantdifferencesinmaternalanemia,birthweight,perinatalmortality,or
congenitalanomalies
ReferenceEntebbeMotherandBabytrial(ClinInfectDis2010Feb
1550(4):531fulltext)
treatmentwithantihelminthicsafterfirsttrimesterofpregnancymay
28/85
20/11/2015
DynaMed
notreduceincidenceofmalaria,pneumonia,ordiarrheainoffspringat1
year(level2[midlevel]evidence)
basedonprespecifiedsecondaryanalysisofEntebbeMotherandBabytrial
withoutintentiontotreatanalysis
90%of2,345liveborninfantswerefollowedtoage1year
nosignificantdifferencesinincidenceofmalaria,pneumonia,diarrhea,or
verticalHIVtransmissioninoffspringorinresponsetoBCG,tetanus,or
measlesimmunizations
ReferenceLancet2011Jan1377(9759):52fulltext,editorialcanbefoundin
Lancet2011Jan1377(9759):6
treatmentwithantihelminthicsduringpregnancymaynotaffectHIV1
viralloadinwomenwithHIVinfection(level3[lackingdirect]evidence)
basedonnonclinicaloutcomefromsubgroupanalysisofEntebbeMotherand
Babytrial
264pregnantwomenwithHIV1infectionwereevaluatedforassociation
betweenantihelminthictreatmentandHIV1viralload
atbaseline67%wereinfectedwith1helminthspecies
HIV1viralloadwassignificantlyhigheratbaselineinwomenwithhookworm
comparedtowomenwithnohelminthinfection
nosignificantchangesinHIV1viralloadcomparingbaselinelevelstolevelsat
deliveryinanygroups
ReferenceJAcquirImmuneDeficSyndr2012Jul160(3):307fulltext
CDCGuidelinesforEvaluationofRefugeesforIntestinalandTissueInvasiveParasitic
InfectionsduringDomesticMedicalExaminationavailablefromCDCDivisionofGlobal
MigrationandQuarantine
Screeningforhemoglobinopathies:
screeningforhemoglobinopathiesinpregnancy
offerscreeningtopatientsofAfrican,SoutheastAsian,andMediterraneandescentdue
toincreasedriskforbeingcarriersofhemoglobinopathies(ACOGLevelA)
appropriatescreeningiscompletebloodcountandhemoglobinelectrophoresis(ACOG
LevelA)
couplesatriskforchildwithsicklecelldiseaseorthalassemiashouldbeoffered
geneticcounseling(ACOGLevelA)
prenataldiagnosisofhemoglobinopathiesbestdonewithDNAanalysisofcultured
amniocytesorchorionicvilli(ACOGLevelA)
ReferenceACOGPracticeBulletin78onhemoglobinopathiesinpregnancy(Obstet
Gynecol2007Jan109(1):229)reaffirmed2014Jan,oratNationalGuideline
Clearinghouse2007Dec24:10920,summarycanbefoundinAmFamPhysician2007
Oct1576(8):1229
inpatientsnotatincreasedrisk,completebloodcount(CBC)withredbloodcellindices
29/85
20/11/2015
DynaMed
consideredsufficientforinitialscreening(1)
seealsoManagementofsicklecelldiseaseinpregnancy
Screeningforthyroiddisease:
AmericanThyroidAssociation(ATA)recommendationsforassessmentofthyroidfunction
inpregnancy
thyroidfunctionscreeninginpregnancy
assessforsymptomsofthyroiddysfunctionand/oruseofthyroidhormone
(levothyroxine)orantithyroidmedications(methimazole,carbimazole,or
propranolol)(ATAGradeB)
checkserumthyroidstimulatinghormone(TSH)levelsearlyinpregnancyinwomen
athighriskforoverthypothyroidism,includingthosewith(ATAGradeB)
historyofthyroiddysfunctionorpriorthyroidsurgery
>30yearsold
symptomsofthyroiddysfunctionorpresenceofgoiter
thyroidperoxidaseantibodypositivity
diabetesmellitustype1orotherautoimmunedisorders
historyofmiscarriageorpretermdelivery
historyofheadorneckradiation
familyhistoryofthyroiddysfunction
morbidobesity(bodymassindex[BMI]40kg/m2)
useofamiodaroneorlithium,orrecentadministrationofiodinatedradiologic
contrast
infertility
residenceinareaofknownmoderatetosevereiodineinsufficiency
insufficientevidencetorecommendfororagainst
thyroidstimulatinghormone(TSH)testingpreconceptioninwomenathighrisk
forhypothyroidism(ATAGradeI)
universalTSHscreeningatfirsttrimestervisit(ATAGradeI)
universalscreeningforantithyroidantibodiesinfirsttrimesterofpregnancy(ATA
GradeI)
screeningeuthyroidwomenwithsporadicorrecurrentabortionorwomen
undergoinginvitrofertilizationforantithyroidantibodies,ortreatinginfirst
trimesterofpregnancywithlevothyroxineorIVimmunoglobulin(ATAGradeI)
levothyroxinetherapyineuthyroidwomenwithantithyroidantibodiesundergoing
assistedreproductiontechnologies(ATAGradeI)
screeningforantithyroidantibodiesinthefirsttrimesterofpregnancy,ortreating
thyroidautoantibodypositive(TAb+)euthyroidwomenwithlevothyroxine,to
preventpretermdelivery(ATAGradeI)
universalfreethyroxine(FT4)screeningofpregnantwomenisnotrecommended
(ATAGradeD)
measurementofthyroidfunctiontestsinpregnancy
30/85
20/11/2015
DynaMed
thyroidstimulatinghormone(TSH)
applytrimesterspecificreferencerangesdefinedinpopulationswithoptimal
iodineintakeforTSHmeasurement(ATAGradeB)
referencerangesthatshouldbeusedforTSHmeasurementsiftrimesterspecific
referencerangesarenotavailableinlaboratory(ATAGradeI)
firsttrimester0.12.5milliunits/L
secondtrimester0.23milliunits/L
thirdtrimester0.33milliunits/L
optimalmethodtoassessserumthyroxine(T4)duringpregnancyismeasurement
ofT4indialysateorultrafiltrateofserumsamplesemployingonlineextraction/liquid
chromatography/tandemmassspectrometry(LC/MS/MS)(ATAGradeA)
ifFT4measurementbyLC/MS/MSnotavailable(ATAGradeA)
usewhichevermeasureofFT4available
beawareoflimitationsofeachmethod
serumTSHmoreaccurateindicationofthyroidstatusinpregnancythanany
alternativemethods
usemethodspecificandtrimesterspecificreferencerangesofserumFT4dueto
widevariationinresultsofFT4assays(ATAGradeB)
ReferenceATAguidelinesforthediagnosisandmanagementofthyroiddisease
duringpregnancyandpostpartum(Thyroid2011Oct21(10):1081PDF)oratNational
GuidelineClearinghouse2012Aug13:36633
universalscreeningmaybemoreeffectivethantargetedcasefindingfor
reducingadversematernalandneonataloutcomesinpregnantwomenatlow
riskforthyroiddysfunction(level2[midlevel]evidence)
basedonsubgroupanalysisofrandomizedtrial
4,562womeninfirst11weeksofgestationwithnohistoryofthyroiddiseasewere
randomizedtouniversalscreeningvs.targetedcasefinding
universalscreeningassociatedwithreducedadversematernalandneonataloutcomes
insubgroupof3,590womenclassifiedasatlowriskforthyroiddysfunction
complicationsperpatient0.74foruniversalscreening(95%CI0.521.02)
complicationsperpatient1.67fortargetedcasefinding(95%CI1.22.13)
nosignificantdifferencesinadversematernalandneonataloutcomesoverall
ReferenceJClinEndocrinolMetab2010Apr95(4):1699fulltext,editorialcanbe
foundinJClinEndocrinolMetab2010Apr95(4):1575fulltext
seealso
Hypothyroidisminadults
Hyperthyroidismandthyrotoxicosis
Psychosocialscreening:
Depression:
depressionreportedin10%15%ofpregnantwomen(2)
screenfordepressionduringpregnancyandinearlypostpartumperiod(1)
31/85
20/11/2015
DynaMed
optimalscreeningtoolnotdefined
potentialscreeningquestionsinclude
haveyoufeltdown,depressed,orhopelessoverthepast2weeks
haveyoufeltlittleinterestorpleasureindoingthingsoverthepast2weeks
factorsassociatedwithincreasedriskforperinataldepressioninclude(1)
maternalanxiety
domesticviolence
lifestress
historyofdepression
lackofsocialsupport
unintendedpregnancy
Medicaidinsurance
lowerincomeand/oreducation
smoking
singlestatus
poorrelationshipquality
complicationsofperinataldepressioninclude(2)
prematurity
lowbirthweight
neurodevelopmentaldelays
issueswithmaternal/infantbonding
3.8%incidenceofsuicidalideationondepressionscreeningamongperinatal
women
basedonretrospectivecohortstudyof22,118womencompletingEdinburghPostnatal
DepressionScalequestionnaireat2428weeksgestationand6weekspostpartum
842(3.8%)reportedsuicidalideation
fromfurtherqualitativestudyof574womenreportingactivesuicidalideation,6(1%)
hadplan,intent,andaccesstomeans
Domesticviolence:
screenpregnantwomenandwomenofchildbearingagefordomesticviolence,and
providereferralorinterventionservicesifwomanscreenspositive(1,2)
domesticviolencerelatedhomicidereportedtobeleadingcauseofdeathforpregnant
womenintheUnitedStates (2)
othercomplicationsofdomesticviolenceinpregnancyinclude(2)
spontaneousabortion
placentalabruption
prematureruptureofmembranes
lowbirthweight
prematurity
cognitivebehavioralandempowermentbasedinterventionsmayreduce
32/85
20/11/2015
DynaMed
domesticviolenceduringpregnancy(level2[midlevel]evidence)
basedonCochranereviewoftrialswithmethodologiclimitations
systematicreviewof10randomizedtrialsevaluatinginterventionstopreventorreduce
domesticviolencein3,417pregnantwomen
alltrialshad1limitationincluding
unclearorinadequateallocationconcealment
lackoforunclearblinding
alltrialscomparedinterventionvs.usualcare
specificinterventionsassociatedwithdecreasedabuseduringpregnancyorpostnatal
period
cognitivebehavioraltherapyin1trialwith306women
interventionbasedonempowermentandempathicunderstandingin1trialwith106
women
partnerviolenceat78monthspostpartumin8.5%withnursehomevisitsincluding
visitsduringpregnancyvs.15.9%withusualcare(notsignificant)in1trialwith181
women
neonataloutcomespoorlyreported
ReferenceCochraneDatabaseSystRev2014Nov12(11):CD009414
abuseduringpregnancyassociatedwithnegativesafetyandfunctionaleffects
upto24monthsafterdelivery
46womenseekingassistanceforpartnerabuseandreportingpregnancyinpast4
monthsevaluatedevery4monthsfor2years
comparedwithnoabuseduringpregnancy,abuseduringpregnancyassociatedwith
significantlyincreasedriskofthreatsofabuse,sexualabuse,physicalabuse,danger
formurder,andposttraumaticstressdisorder(PTSD)atbaseline
oversubsequent24months,riskremainedhigherforwomenwhoexperiencedabuse
duringpregnancyfor
murderfor8monthsafterdelivery
depressionat4,8,16,and20monthsafterdelivery
PTSDfor24monthsafterdelivery
childrenlivingmotherswhowereabusedduringpregnancyhadmorebehavioral
problems(especiallydepressionandanxiety)for24monthsafterdelivery
violenceagainstpregnantwomenmaybemorecommonthansomeotherconditionsfor
whichtheyareroutinelyscreened(JAMA1996Jun26275(24):1915)
Screeningandpreventionofpregnancyrelatedcomplications:
Gestationaldiabetes:
gestationaldiabetesdefinedasglucoseintoleranceduringpregnancy(1)
screeningforgestationaldiabetestypicallyperformedat2428weeksgestationdueto
pregnancyrelatedhormonalchanges (1)
33/85
20/11/2015
DynaMed
AmericanCollegeofObstetriciansandGynecologists(ACOG)committeeopinionon
screeninganddiagnosisofgestationaldiabetes
1houroralglucosetolerancetestshouldbeperformedafter50gramglucoseload
ifdiagnosticthresholdreached,perform3houroralglucosetolerancetestusing100
gramglucoseload
selectionbyhealthcareprovidersofeither135mg/dLor140mg/dLasconsistent
thresholdfor1hourglucosescreeningtestsuggested,consideringcommunity
prevalenceofGDMandotherfactors
diagnosisofGDMbasedonresultsof100g3houroralglucosetolerancetest(which
hasevidenceofimprovementwithtreatment)
eitherdiagnosticcriteriaappropriatetousepositivediagnosisrequires2thresholds
metorexceededbutpractitionersandinstitutionsshouldselectasinglesetof
diagnosticcriteriaforconsistentusewithintheirpatientpopulations(ACOGLevelB)
CarpenterandCoustanplasmaorserumglucoselevels
fasting95mg/dL(5.3mmol/L)
1hour180mg/dL(10mmol/L)
2hour155mg/dL(8.6mmol/L)
NationalDiabetesDataGroupplasmaglucoselevels
fasting105mg/dL(5.8mmol/L)
3hour145mg/dL(8mmol/L)
ReferenceACOGPracticeBulletinNo.137ongestationaldiabetesmellitus(Obstet
Gynecol2013Aug122(2Pt1):406)
seeGestationaldiabetes(GDM)foradditionalinformation
Hypertensioninpregnancy:
monitorbloodpressureateachprenatalvisit,andadvisewomenofwarningsignsof
preeclampsia(2)
considerbaselineurineproteinandpreeclampsialabtesting(1,2)
routinedipstickanalysisisbecominglesscommonduetoevidenceshowinglimited
clinicalbenefit
proteinuriadefinedas300mgofproteinina24hoururinespecimen
factorsassociatedwithincreasedriskforpreeclampsia(2)
historyofpreeclampsia
chronichypertension
lowdietarycalcium(<700mg)
prophylactictreatmentstoreduceriskforpreeclampsia(2)
calciumsupplementationreportedtoreduceriskforpreeclampsiaby30%50%in
womenwithlowdietarycalciumintake
lowdoseaspirinfrom1236weeksgestationreportedtoreduceriskforpreeclampsia
34/85
20/11/2015
DynaMed
byabout20%inwomenwith
historyofpreeclampsia
chronichypertension
diabetes
autoimmunedisease
renaldisease
currentgestationalhypertension
visualdipsticktestingdoesnotappeartoeffectivelydiagnoseorexclude
thresholdlevelproteinuriainpregnantwomen(level2[midlevel]evidence)
basedonsystematicreviewofdiagnosticcohortstudieslimitedbyclinical
heterogeneity
systematicreviewof7observationalstudiesevaluatingdipstickurinalysisaspredictor
ofproteinuriain1,841urinesamplefrompregnantwomen
6trialsusedreferencestandard24hoururinesample(definingproteinuriaas300
mg/24hour)1trialusedproteinconcentrationasreferencestandard
significantheterogeneityinperformanceofdipsticktest(p<0.001)
fordiagnosisofproteinuria,visualdipstickurinalysiswith1+proteinhad
pooledpositivelikelihoodratio3.48(95%CI1.667.27)
poolednegativelikelihoodratio0.6(95%CI0.450.8)
limiteddataandpoormethodologicmethodslimitabilitytoanalyzeresultsfor>1+
proteinuria
Pretermlabor:
riskfactorsforpretermlaborinclude
priorprematurebirth(strongestriskfactor)
cervicalriskfactors
incompetentcervix
shortcervix(commonlydefinedas<25mmbefore24weeksgestation)
excisionaltreatmentofcervicaldysplasia
infections
bacterialvaginosis
Chlamydiatrachomatis
otherinfections
drugsandtoxins
tobacco
alcohol
somemedications(steroids,theophylline)
pollutants
othertoxins(suchasdiethylstilbestrol[DES]exposureinutero)
psychologicalfactors
depression
35/85
20/11/2015
DynaMed
stressoranxiety
lowersocioeconomicstatus
periodontaldisease(butevidenceinconsistent)
fetalriskfactors
multiplegestation
congenitalanomalies
earlyfetalgrowthrestriction
uterineandplacentalfactors
placentalabruption
placentaprevia
polyhydramnios
uterineanomalies
uterineleiomyoma
subchorionichemorrhage
vaginalbleeding(firsttrimester)
subchorionichematoma
otherpossibleriskfactors
trauma
douching
autoimmuneconditions
polycysticovarysyndrome
increasedlevelsofinflammatorymarkers
hereditaryfactor
lowfishintake
physicallydemandingworkduringpregnancy
maternalage<20yearsor>40years
lowmaternalprepregnancyweight
maternalweightgain<0.27kg(0.6lbs)/week
infertilitytreatment
timeintervalbetweenpregnancies<18monthsor>59months
ethnicity(blackwomen)
factorsnotassociatedwithincreasedriskofpretermlabor
groupBstreptococcal(GBS)colonization
priorabortion
seeRiskfactorsforpretermlaborandprematurebirthfordetails
prophylactictreatmentsforwomenathighriskforpretermbirth(2)
progesterone(weeklyinjectionsfrom1637weeksgestationordailyvaginal
suppositories)reportedtoreduceriskforpretermbirthbyabout35%inwomenwith
historyof
spontaneouspretermbirth
pretermprematureruptureofmembranes(PPROM)
36/85
20/11/2015
DynaMed
cervicalcerclagemayreduceriskforpretermbirthinwomenwithashortcervixand
historyofpretermbirth,butevidenceismixed
vaginalprogesteronehasbeenreportedtoreduceriskforpretermbirthinwomenwith
asymptomaticshortcervixidentifiedonultrasound
smokingcessationandtreatmentofgenitalinfectionswhenapplicable
repeatdigitalcervicalassessmentdoesnotdetectriskfororreduceratesof
pretermbirth(level1[likelyreliable]evidence)
basedonCochranereview
systematicreviewofrandomizedtrialscomparingrepeatdigitalcervicalassessment
(RDCA)withinternalexamornointernalexam(unlessclinicallyindicated)
2trialswith7,163womenmetinclusioncriteria
studieswithRDCAasacomponentofmultipletestswerenotincluded
nosignificantdifferencebetweengroupsinpretermbirthat<37weeks(oddsratio
1.05,95%CI0.851.31)inanalysisofbothtrials
1trialwith5,863womenfoundnosignificantdifferencebetweengroupsinpreterm
birthat<34weeks,pretermprematureruptureofmembranes,hospitaladmission
before37weeks,caesareansection,useoftocolyticdrugs,orneonataloutcomes
insufficientevidencetoevaluateadverseeffectsofdigitalcervicalassessment
Otheradversepregnancyoutcomes:
factorsassociatedwithriskofcomplicatedpregnancyinhealthynulliparouswomenin
prospectivecohortstudy
5,628healthynulliparouswomenwithsingletonpregnancywerefollowedfrom<15
weeksgestationalagetopostpartum
61.3%haduncomplicatedpregnancy(definedasnormotensivepregnancywithdelivery
at>37gestationalweeksresultinginlivebornbabynotsmallforgestationalageand
absenceofothersignificantpregnancycomplications)
factorsat15weeksgestationalageassociatedwithincreasedriskofcomplicated
pregnancyincluded
overweightorobese
higherbloodpressure
misuseofdrugsinfirsttrimester
lowersocioeconomicstatus
factorsassociatedwithdecreasedriskofcomplicatedpregnancyincluded
prepregnancyfruitintake3timesdaily
paidemploymentat15gestationalweeks
ReferenceBMJ2013Nov21347:f6398fulltext
measurementofplasmaestriollevelsnotassociatedwithreducedfetalor
perinatalmortalityinwomenwithhighriskpregnancy(level2[midlevel]
evidence)
basedonCochranereviewwithlimitedevidence
37/85
20/11/2015
DynaMed
systematicreviewofrandomizedorquasirandomizedtrialsevaluatingbiochemical
testsofplacentalfunctioninwomenwithhighrisk,lowrisk,orunselectedpregnancy
only1quasirandomizedtrialfoundassessingplasmaestrioltestingin622womenwith
highriskpregnancy
allwomenhadplasmaestriolassessedandwereallocatedbyhospitalrecord
numbertorevealedvs.concealedtestresults
nosignificantdifferencesinfetaldeath,perinatalmortality,inductionoflabor,or
electivecesareansectioncomparingrevealedvs.concealedresults
reviewauthorsnotethatbiochemicaltestinghasbeensupersededbybiophysical
testingforantenatalassessmentoffetus
ReferenceCochraneDatabaseSystRev2012Aug15(8):CD000108
insufficientevidencetoevaluateeffectsoftopicalcorticosteroidsfor
dermatologicalconditionsonpregnancyoutcomes
systematicreviewofrandomizedtrialsandobservationalstudiesevaluatingeffectsof
topicalcorticosteroidsonpregnancyoutcomes
2cohortstudiesand5casecontroltrialswith659,675womenmetinclusioncriteriaall
lowquality
moststudiesdidnotfindsignificantassociationsbetweentopicalcorticosteroidsand
pregnancyoutcomesincludingmodeofdelivery,congenitalabnormality,preterm
delivery,andstillbirth
insingletrials
increasedriskoforofacialcleftwithfirsttrimesteruseofcorticosteroids
increasedriskoflowbirthweightwithverypotenttopicalcorticosteroids
ReferenceCochraneDatabaseSystRev2009Jul8(3):CD007346
norandomizedorquasirandomizedtrialsidentifiedevaluatinginterventionsfor
womenwithfemalegenitalmutilationwhoarepregnantorplanningtobecome
pregnant
ReferenceCochraneDatabaseSystRev2013Feb28(2):CD009872
GeneticTesting
Generalinformation:
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendationson
identificationandreferralofmaternalgeneticconditionsinpregnancy
managementofmaternalgeneticconditionsduringpregnancyiscomplexanda
multidisciplinaryapproachmaybeneeded
considerpreconceptionevaluationwithobstetrician/gynecologist,geneticsspecialists,
maternalfetalmedicinespecialists,andotherappropriatesubspecialistsinorderto
optimizecareinwomenwithgeneticconditionsoratriskofhavingaparticulargenetic
condition
38/85
20/11/2015
DynaMed
offerpreimplantationgenetictestingwithinvitrofertilizationbyreproductive
endocrinologistorprenataldiagnostictestingoncepregnancyisestablishedinwomen
withestablishedcausativegeneticmutationswhodesireprenatalgenetictesting
performinitialprenatalexamearlyinfirsttrimesterinpregnantwomenwithgenetic
condition
ReferenceObstetGynecol2015Oct126(4):e49
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendationson
screeningforfetalchromosomalabnormalities
screeningandinvasivediagnostictestingshouldbeavailabletoallwomenpresenting
forprenatalcarebefore20weeksgestation,regardlessofmaternalagecounsel
womenondifferencebetweenscreeningandinvasivediagnostictesting(ACOGLevel
B)
screeningwithultrasoundfornuchaltranslucencyaloneislesseffectivethancombined
testslookingatnuchaltranslucencyandbiochemicalmarkers(ACOGLevelA)
offergeneticcounselingandoptionofchorionicvillussamplingorsecondtrimester
amniocentesistowomenwithincreasedriskoffetuswithaneuploidyonfirsttrimester
screening(ACOGLevelA)
offertargetedultrasoundexam,fetalechocardiogram,orbothiffetalnuchal
translucency3.5mminfirsttrimesterdespitenegativeaneuploidyscreenornormal
fetalchromosomes(ACOGLevelB)
subsequentsecondtrimesterscreeningafterfirsttrimesterscreeningnotindicated
unlessperformedascomponentofintegrated,stepwisesequential,orcontingent
sequentialtest(ACOGLevelC)
integratedfirstandsecondtrimesterscreeningismoresensitivewithlowerfalse
positiveratesthanfirsttrimesterscreeningalone(ACOGLevelC)
screeningoptionsforfetalaneuploidyandneuraltubedefects
infirsttrimester(typicallyperformedat911weeksgestation)
fetalultrasound(alsocalledgeneticultrasound)toassessnuchaltranslucency
(NT)
NTmeasurementwithserumtesting(alsocalledcombinedfirsttrimester
screening)
insecondtrimester(typicallyperformedat1519weeksgestation)
triplescreeningwithserummarkersalone
quadruplescreening(tripletestingplusinhibinA)
infirstandsecondtrimesters
combinationofserumbiomarkersandultrasoundtesting
integratedscreeningwithserumtestingonly(sameasabovebutnoultrasound
assessmentofnuchaltranslucency)
ReferenceACOGpracticebulletinno.77onscreeningforfetalchromosomal
abnormalities(ObstetGynecol.2007Jan109(1):21727),reaffirmedJanuary2014,or
atNationalGuidelineClearinghouse2007Dec24:10921
39/85
20/11/2015
DynaMed
typicalfindingsonfetalultrasoundconcerningDownSyndromeinclude
increasednuchalfoldthickness
presenceofthickenednuchalfoldinsecondtrimesterultrasoundassociatedwith
increasedriskforDownsyndromeandabsenceofthickenednuchalfoldmayrule
outDownsyndrome
absentorhypoplasticnasalboneonultrasoundmayhelpdetectDownsyndrome
intrauterinegrowthrestriction
mildcerebralventriculomegaly
choroidplexuscysts
cystichygromas
firsttrimestercombinationscreeningmayidentifyorruleoutfetaltrisomy21
secondtrimesterscreeningwith45serummarkersmaynotbesubstantiallymore
sensitivethantestsusing23markers(level2[midlevel]evidence)
secondtrimesteramniocentesisappearssaferthantranscervicalchorionicvilloussampling
orearlyamniocentesisduetofewerlostpregnancies(level2[midlevel]evidence)
maternalplasmacellfreefetalDNAscreening
appearstohavehighsensitivityandspecificityforfetaltrisomies21and18inhighrisk
women(level2[midlevel]evidence)
mayreducetheneedforinvasivefollowuptestingcomparedtostandardaneuploidy
screening(level2[midlevel]evidence)
seeScreeningforDownsyndromefordetails
reviewofexpandedgeneticcarrierscreeninginreproductivemedicine(ObstetGynecol
2015Mar125(3):653)
Screeningtests:
mostguidelinesrecommendallwomenbeofferedaneuploidyscreeninginpregnancy
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendedoptions
foraneuploidyscreening
infirsttrimester(typicallyperformedat911weeksgestation)
fetalultrasound(alsocalledgeneticultrasound)toassessnuchaltranslucency
(NT)
NTmeasurementwithserumtesting(alsocalledcombinedfirsttrimester
screening),including
pregnancyassociatedplasmaproteinA(PAPPA)
freeortotalhumanchorionicgonadotrophin(hCG)
insecondtrimester(typicallyperformedat1519weeksgestation)
triplescreeningwithserummarkersalone,including
maternalserumalphafetoprotein(MSAFP)
hCG
unconjugatedestradiol
quadruplescreening(tripletestingplusinhibinA)
inbothfirstandsecondtrimesters
40/85
20/11/2015
DynaMed
integratedscreeningusingcombinationofserumbiomarkersandultrasound
testing
serumtestingforpregnancyassociatedplasmaproteinA(PAPPA)plus
ultrasoundassessmentofnuchaltranslucencyinfirsttrimester
quadruplescreeninginsecondtrimester
integratedscreeningwithserumtestingonly(sameasabovebutnoultrasound
assessmentofnuchaltranslucency)
ReferenceAmericanCollegeofObstetriciansandGynecologists(ACOG)practice
bulletinonscreeningforfetalchromosomalabnormalities(ObstetGynecol2007
Jan109(1):217),reaffirmedJanuary2014,oratNationalGuidelineClearinghouse
2007Dec24:10921
seeScreeningforDownsyndromeforadditionalinformation
allscreeningtestsgenerallyreportresultsinriskofaneuploidy(2)
positiverateabout5%,mostofwhicharefalsepositives
reporteddetectionrate69%87%
screeningtestsmayhelpwomen35yearsolddecidewhethertoproceedwith
invasivetesting(2)
16.9%chromosomalabnormalitiesconsiderednotcurrentlydetectablewith
noninvasiveprenataltestingamongwomenwithpositiveaneuploidyscreenand
furtherinvasivetesting
basedoncohortstudyof1,324,607pregnantwomenwithtraditionalnoninvasive
prenatalscreening
5.2%(68,990)screenpositive
amongscreenpositivewomen,37.8%(26,059)hadinvasivediagnostictesting
amongwomenwithinvasivediagnostictesting,11.5%(2,993)hadabnormal
karyotyperesult
amongwomenwithabnormalkaryotyperesultsoninvasiveprenataltesting
83.1%predictedtobedetectablewithcurrentnoninvasiveprenataltesting
16.9%classifiedasnotcurrentlydetectable
ReferenceObstetGynecol2014Nov124(5):979
maternalplasmacellfreefetalDNAscreening
SocietyforMaternalFetalMedicinerecommendsagainstofferingnoninvasiveprenatal
testing(NIPT)tolowriskpatientsormakeirreversibledecisionsbasedontheresults
ofthisscreeningtest(ChoosingWisely2014Feb3)
maternalplasmacellfreefetalDNAscreeningappearstohavehigh
sensitivityandspecificityforfetaltrisomies21,18,13,andmonosomyXin
bothhighandlowriskwomen(level2[midlevel]evidence)
basedondiagnosticcohortstudywithoutvalidation
1,064adultwomen(medianmaternalage30years,mediangestationalage14
weeks)withsingletonpregnanciesat>7weeksgestationhadcellfreefetalDNA
testingandamniocentesis,orchorionicvilloussamplingwithconfirmatory
41/85
20/11/2015
DynaMed
fluorescenceinsituhybridization,orcytogenetickaryotypeanalysis,orgenetic
testingofcordblood,buccalsample,saliva,orproductsofconception(reference
standard)todeterminefetalploidystatus
testingconsistedofamplification,sequencing,andanalysisofcellfreeDNAusing
NextgenerationAneuploidyTestUsingSingleNucleotidePolymorphismalgorithm
51%definedashighriskforaneuploidy(abnormalserumscreen,ultrasound
abnormality,ormaternalage35years)
prevalencebyreferencestandard
67casestrisomy21
32casestrisomy18
14casestrisomy13
12casesmonosomyX
966womenwithcompletedataincludedinanalysis
diagnosticperformanceofmaternalplasmacellfreeDNAtestingfordetectionof
trisomy21
sensitivity100%
specificity100%
trisomy18
sensitivity96%
specificity99.9%
trisomy13
sensitivity100%
specificity100%
monosomyX
sensitivity90%
specificity99.9%
sensitivitiesandspecificitiessimilarinhighandlowriskpopulations
ReferenceObstetGynecol2014Aug124(2Pt1):210,editorialcanbefoundin
ObstetGynecol2014Aug124(2Pt1):199
maternalplasmacellfreeDNAtestinghashighersensitivityandspecificity
fortrisomy21thanstandardscreening(level1[likelyreliable]evidence)
15,841women18yearsold(meanage31years)withsingletonpregnancyhad
firsttrimesteraneuploidyscreeningwithcellfreeDNAtestingandstandard
screening(meangestationalage12.5weeks)
standardscreeningincludedmeasurementofnuchaltranslucency,serumPAPPA,
andtotalorfreebetasubunitofhumanchorionicgonadotropin
cellfreeDNAanalysiswasblindedtoallclinicaldata,includingultrasoundand
standardscreeningresults
patientsreceivedstandardscreeningresults,butcellfreeDNAtestingresults
werenotgiventopatientsortheirproviders
42/85
20/11/2015
DynaMed
referencestandardwasphysicalexaminationofnewbornandgenetictestingif
performed
68pregnancies(0.43%)hadanychromosomalabnormalities,and38pregnancies
hadtrisomy21(0.24%)
comparingcellfreeDNAtestingvs.standardscreeningfordetectionoftrisomy21
sensitivity100%vs.78.9%(p=0.008)
specificity99.9%vs.94.6%(p<0.001)
positivepredictivevalue80.9%vs.3.4%(p<0.001)
negativepredictivevalue100%vs.99.9%(p=0.005)
cellfreeDNAtestingalsoassociatedwithsignificantlyincreasedspecificityfor
Trisomy18andTrisomy13vs.standardscreening
ReferenceNoninvasiveExaminationofTrisomy(NEXT)trial(NEnglJMed2015
Apr23372(17):1589),editorialcanbefoundinNEnglJMed2015Apr
23372(17):1666
maternalplasmacellfreefetalDNAscreeningappearstohavehigh
sensitivityandspecificityforfetaltrisomies21and18inhighriskwomen
(level2[midlevel]evidence)
basedondiagnosticcohortstudywithtestunderinvestigationandreference
standardresultsnotavailableforallpatients
3,430adultwomen(medianage36years)withsingletonpregnancieshadcellfree
fetalDNAtestingandinvasivetestingwithchorionicvillussamplingoramniocentesis
(referencestandard)fordetectionoffetaltrisomies21,18,and13
priortoenrollment,invitedwomenjudgedbyattendingphysicianstobeathighrisk
forfetalaneuploidy
testingconsistedofmassivelyparallelsequencingofmaternalplasmacellfreefetal
DNAfrom10mLsampleofwholeblood
3,322womenwithcompletedataandwithoutcomplexkaryotypeswereincludedin
analysis
137cases(4.1%)fortrisomy21
predictiveperformanceofmaternalplasmacellfreeDNAtestingfordetectionof
trisomy21was
sensitivity100%
specificity99.9%
negativepredictivevalue100%
trisomy18was
sensitivity92.3%
specificity100%
positivepredictivevalue100%
43/85
20/11/2015
DynaMed
ReferenceAmJObstetGynecol2014Oct211(4):365.e1
cellfreefetalDNAanalysisofmaternalplasmamayhelpdiagnosetrisomies
13,21,and18inwomenathighriskforfetalaneuploidies,butmaymissother
pathogenicaneuploidiesinwomenwithabnormalultrasound(level2[mid
level]evidence)
basedonretrospectivediagnosticcohortstudywithtestresultsnotavailableforall
womenandwithsubgroupanalysis
900womenwithsingletonortwinpregnancyatgestationalage10weekshad
noninvasivematernalplasmacellfreefetalDNAanalysis(bymassiveparallel
sequencing)andconventionalfetalkaryotyping(referencestandard)
allwomenwereconsideredathighriskforfetalaneuploidyduetoage>38
years,abnormalserumscreeningresults,orhistoryofpregnancywithtrisomy
376womenhadfetalabnormalitiesonultrasound
14womenexcludedforunavailabilityofkaryotypeornonreportablecellfreefetal
DNAassay
prevalenceofabnormalfetalkaryotypes
trisomy13in1.4%
trisomy18in2.8%
trisomy21in8.6%
otherpathogenicchromosomalabnormalitiesin2.8%
overalldiagnosticperformanceofcellfreefetalDNAanalysis
fordetectionoftrisomy13,sensitivity100%andspecificity99.9%
fordetectionoftrisomy18,sensitivity88%andspecificity99.9
fordetectionoftrisomy21,sensitivity100%andspecificity99.9%
insubgroupof290womenwithnormalcellfreeDNAresultswhohadabnormal
ultrasound,8%hadpathogenicaneuploidiesotherthantrisomies21,18,and13
identifiedbykaryotype
ReferenceObstetGynecol2015Jun125(6):1330
maternalplasmacellfreeDNAscreeningforfetaltrisomies21and18may
reducetheneedforinvasivefollowuptestingcomparedtostandard
aneuploidyscreening(level2[midlevel]evidence)
basedonvalidationcohortstudywithtestunderinvestigationandreference
standardresultsnotavailableforallpatients
2,042adultwomen(meanage30years)fromgeneralobstetricpopulationwith
singletonpregnanciesofgestationalage8weekshadcellfreeDNAtestingand
standardaneuploidyscreeningfordetectionoffetaltrisomies21,18,and13
cellfreeDNAtestingconsistedofmassivelyparallelsequencingofmaternal
plasmacellfreeDNAfrom10mLsampleofperipheralvenousbloodinfirst,
second,orthirdtrimester
standardaneuploidyscreeningincludedassaysforfirstorsecondtrimester
44/85
20/11/2015
DynaMed
serummarkerswithorwithoutultrasoundfetalnuchaltranslucencymeasurement
referencestandardwasnewbornphysicalexamorkaryotypeanalysisfornonlive
birth
1,914womenwithoutlosstofollowupandhavingresultsforkaryotypeanalysis,
cellfreeDNAtesting,andstandardaneuploidyscreeningwereincludedinanalysis
PredictivePerformanceofScreeningTestsforDetectionofTrisomy21and
Trisomy18:
Performance
CellfreeDNA
StandardAneuploidy
Measure
Trisomy21(Downsyndrome)
Sensitivity
100%
100%
Specificity
99.7%
96.4%
Positivepredictive
45.5%
4.2%
100%
100%
value
Negativepredictive
value
Trisomy18(Edwards'syndrome)
Sensitivity
100%
100%
Specificity
99.8%
99.4%
Positivepredictive
40%
8.3%
100%
100%
value
Negativepredictive
value
cellfreeDNAtestingassociatedwithsignificantlyincreasedspecificityandpositive
predictivevaluecomparedtostandardaneuploidyscreeningforbothtrisomy21and
trisomy18
ReferenceNEnglJMed2014Feb27370(9):799,editorialcanbefoundinNEngl
JMed2014Feb27370(9):874
noninvasiveprenatalsexdeterminationusingcellfreefetalDNAappears
effective(level2[midlevel]evidence)
basedonsystematicreviewwithheterogeneity
systematicreviewof57diagnosticstudiesevaluatingnoninvasiveprenatalsex
45/85
20/11/2015
DynaMed
determinationusingcellfreefetalDNAisolatedfrommaternalbloodorurinein
6,541pregnancies
3,524singletonmalefetuses
3,017singletonfemalefetuses
heterogeneitypartiallyexplainedwithpoorertestperformancebefore7weeks
gestationandgreatesttestperformanceafter20weeksgestation
fordetectingYchromosomesequences(definingmalegender),noninvasive
prenatalsexdeterminationusingcellfreefetalDNAhadinoverallmetaanalysis
sensitivity95.4%
specificity98.6%
testingat<7weeksgestationhadlowsensitivityandspecificity
ReferenceJAMA2011Aug10306(6):627
combinedscreeningfortrisomy21(Downsyndrome)andtrisomy18
firstandsecondtrimesterscreeningprotocolsmayhelpdetectDownsyndromeand
nonDownaneuploidies,butduetolowprevalenceofdisease,mostpositiveresultswill
befalsepositives
firstandsecondtrimesterscreeningprotocolsmayhelpdetectDown
syndromeandnonDownaneuploidies(level2[midlevel]evidence)
basedondiagnosticcohortstudywithoutindependentreferencestandard
36,171patientswithsingletonpregnanciesat10weeks3daysgestationthrough
13weeks6daysgestationhadfirsttrimesternuchaltranslucencytestand
returnedat1518weeksgestationforsecondtrimesterquadruplescreening
patientswithcystichygromahadcombinedtestinfirstsemester(nuchal
translucency,PAPPA,andfreebetahCG)
quadruplescreeninginsecondtrimesterincludedserumalphafetoprotein,
totalhCG,unconjugatedestriol,andinhibinA
35,236patientscompletedsecondtrimesterscreening
positivescreenforDownSyndromedefinedaspredictedrisk1in300forboth
trimesters
positivescreenforTrisomy18definedaspredictedrisk1in100
77casesofnonDownaneuploidiesidentified
diagnosticperformanceoffirsttrimesterscreeningfordetectionofnonDown
aneuploidyincohortwith0.19%prevalenceofnonDownaneuploidy
sensitivity79%
specificity94%
diagnosticperformanceofsecondtrimesterscreeningfordetectionofnonDown
aneuploidyincohortwith0.08%prevalenceofnonDownaneuploidy
46/85
20/11/2015
DynaMed
sensitivity69%
specificity91%
ReferenceObstetGynecol2007Sep110(3):651
firsttrimestercombinationofmaternalage,freebetahCG,pregnancy
associatedplasmaproteinA,andfetalnuchaltranslucencyappears
sensitivefortrisomy18andDownsyndrome,butpositivepredictivevalue
low(level2[midlevel]evidence)
basedondiagnosticcohortstudywithoutindependentreferencestandard
8,216womenwithsingletonpregnancieshadcombinationscreeningat7497
daysgestation(10weeks4daysto13weeks6daysgestation)andgenetic
outcomeassessedbyfetalkaryotypingorinfantphenotypeevaluationatbirth
trisomy18in11cases(0.13%incidence)
Downsyndromein61cases(0.74%incidence)
diagnosticperformanceofcombinationscreening
fordetectionoftrisomy18(positivescreendefinedaspredictedrisk1in
150)
sensitivity90.9%
falsepositiverate2%
sensitivityinwomen35yearsold100%
withoutuseofultrasoundfornuchaltranslucency
sensitivity81.8%
falsepositiverate3.3%
fordetectionofDownsyndrome(positivescreendefinedaspredictedrisk1
in270)
sensitivity85.2%
sensitivityinwomen35yearsold89.8%
withoutuseofultrasoundfornuchaltranslucency
sensitivity85.2%
ReferenceNEnglJMed2003Oct9349(15):1405fulltext,commentarycanbe
foundinNEnglJMed2004Feb5350(6):619,AmFamPhysician2004Feb
1569(4):939,JFamPract2004Mar53(3):184
EBSCOhostFullText
chromosomeselectivesequencingofmaternalplasmacellfreeDNAmay
helpdetecttrisomy21andtrisomy18(level2[midlevel]evidence)
47/85
20/11/2015
DynaMed
basedon2diagnosticcasecontrolstudies
diagnosticcasecontrolof250womenwithdisomicpregnancies,72withtrisomy
21pregnancies,and16withtrisomy18pregnanciesrandomlyassignedto
derivationorvalidationcohort
derivationcohortincluded127disomicpregnancies,36trisomy21
pregnancies,and8trisomy18pregnancies
validationcohortincluded123disomicpregnancies,36trisomy21pregnancies,
and8trisomy18pregnancies
inderivationcohort
biochemicalassaywasdevelopedforsequencinganddigitallyanalyzing
selectedregionsofchromosomes21and18
fetalfractionoptimizedriskoftrisomyevaluation(FORTE)algorithm
developedfordeterminingtrisomyriskbasedondigitalsequenceanalysis
invalidationcohort,FORTEalgorithmcorrectlydiscriminated
100%oftrisomy21cases
100%oftrisomy18cases
100%ofdisomiccases
seearticlefordetailsofFORTEalgorithm
ReferenceAmJObstetGynecol2012Apr206(4):319.e1fulltext,editorial
canbefoundinAmJObstetGynecol2012Apr206(4):269
nesteddiagnosticcasecontrolofmaternalplasmafrom300pregnancieswith
euploidfetuses,50pregnancieswithtrisomy21,and50pregnancieswithtrisomy
18evaluatedat1113weeksgestation
chromosomeselectivesequencingofcellfreeDNAdiscriminated100%of
trisomy21casesand98%oftrisomy18casesfromeuploidpregnancies
ReferenceAmJObstetGynecol2012Apr206(4):322.e1fulltext,editorial
canbefoundinAmJObstetGynecol2012Apr206(4):269
massivelyparallelsequencingofmaternalplasmaDNAmayhelpdetect
Turnersyndrome(level2[midlevel]evidence)
basedondiagnosticcohortstudywithnestedcasecontrolanalyses
2,882womenwithsingletonpregnancyat822weeksgestationhadinvasive
prenatalproceduretodeterminefetalkaryotypeand532samples(allpregnancies
withabnormalkaryotypeandbalancednumberofrandomlyselectedpregnancies
withnormalkaryotype)furtherevaluated
massivelyparallelsequencinginvolvessimultaneoussequencingofmaternalplasma
DNAusingminiature,parallelplatformsinordertosequencemassiveshortreads
withoutrequiringastepforphysicalseparation
16casesofTurnersyndromebykaryotype
abilityofmassivelyparallelsequencingofmaternalplasmaDNAtodetectTurner
syndrome
sensitivity93.8%
48/85
20/11/2015
DynaMed
specificity99.8%
ReferenceObstetGynecol2012May119(5):890,editorialcanbefoundinObstet
Gynecol2012May119(5):883
massivelyparallelsequencingofmaternalplasmaDNAmayhelpdetect
Turnersyndromeincasesoffetalnuchalcystichygroma(level2[midlevel]
evidence)
basedondiagnosticcasecontrolstudy
113womencarryingfetuseswithcystichygromahadmassivelyparallelsequencing
ofmaternalplasmaDNA
69fetuses(61%)hadabnormalkaryotype(21casesofTurnersyndrome)
diagnosticperformanceofmassivelyparallelsequencingofmaternalplasmaDNAto
detectTurnersyndrome
sensitivity95.2%
specificity100%
ReferenceObstetGynecol2013May121(5):1057
reviewofantenatalscreeninganddiagnosisoffetalchromosomalabnormalitiescanbe
foundinAmFamPhysician2009Jan1579(2):117
EBSCOhostFullTextfulltext
reviewofassociationbetweenfirstandsecondtrimesteraneuploidymarkersand
adverseobstetricoutcomesinabsenceofaneuploidyorneuraltubedefectscanbefound
inObstetGynecol2010May115(5):1052
Amniocentesisandchorionicvillussampling:
offerinvasivegenetictesting(chorionicvilloussamplingat1113weeksgestationor
amniocentesisat15weeksgestation)to(2)
allpregnantwomenaged35yearsduetoincreasedriskforDownsyndrome
womenwithpositivescreeningtestforDownsyndrome
secondtrimesteramniocentesisappearssaferthantranscervicalchorionic
villoussamplingorearlyamniocentesis(level2[midlevel]evidence)
basedonCochranereviewwithincompleteassessmentoftrialquality
systematicreviewof16randomizedtrialscomparingamniocentesisandtranscervical
chorionicvilloussampling(CVS)byeithertransabdominalortranscervicalroute
ifearlierdiagnosisneeded(914weeksgestation),transabdominalCVSpreferableto
transcervicalCVSwhichispreferabletoearlyamniocentesis
pregnancylossincludedterminationsofpregnancy
comparingsecondtrimesteramniocentesisvs.notestingin1trialwith4,606patients
pregnancylossin3.2%vs.2.3%(p=0.058)
spontaneousmiscarriagerate2.1%vs.1.3%(p=0.041,NNH125)
comparingearlyvs.secondtrimesteramniocentesisin1trialwith4,334patients
pregnancylossin7.6%vs.5.9%(p=0.025,NNH58forearlyamniocentesis)
talipesequinovarusin1.3%vs.0.09%(p=0.0003,NNH82forearly
amniocentesis)
comparingtranscervicalCVSvs.secondtrimesteramniocentesis
49/85
20/11/2015
DynaMed
pregnancylossin14.5%vs.11%inanalysisof4trialswith6,527patients(p=
0.01,NNH28),resultslimitedbysignificantheterogeneity(p=0.03)
spontaneousmiscarriagein12.9%vs.9.4%inanalysisof3trialswith5,506
patients(p=0.02,NNH28),resultslimitedbysignificantheterogeneity(p=0.02)
comparingtransabdominalCVSvs.amniocentesis
spontaneousmiscarriagein1.3%vs.2.3%withearlyamniocentesis(p=0.007,
NNT100)inanalysisof4trialswith5,491patients
talipesin0.19%vs.0.9%withearlyamniocentesis(p=0.001,NNT141)inanalysis
of4trialswith5,305patients
nosignificantdifferencesinpregnancylossratescomparedto2ndtrimester
amniocentesis(1trialwith2,069patients)orearlyamniocentesis(4trialswith
5,491patients)
transabdominalCVSmaybeeasiertoperformthantranscervicalCVS
ReferenceCochraneDatabaseSystRev2003(3):CD003252
chorionicvillussamplingat1113weeksgestationnotassociatedwithincreased
riskofhypertensivedisordersinpregnancy
basedoncohortstudy
31,138womenwithsingletonpregnanciesat11weeksto13weeks6daysgestation
withavailablemeasurementsoffreebetahCGandpregnancyassociatedplasma
proteinAwhodidnothaveamniocentesisandwhosepregnancysurvivedbeyond23
weeksgestationevaluated
subsequentdevelopmentof
gestationalhypertensionin2.8%
preeclampsiain2.2%
chorionicvillussamplingin7.3%
chorionicvillussamplingnotassociatedwithincreasedriskofearlypreeclampsia,late
preeclampsia,orgestationalhypertension
ReferenceObstetGynecol2010Aug116(2Pt1):374
communicatingrapidtestresultsfromamniocentesishasinconsistentevidence
foreffectonmaternalanxiety
systematicreviewof2randomizedtrialscomparingadditionofrapidtesttostandard
fullkaryotypingvs.fullkaryotypingalonein286womenhavingamniocentesis
1trialwith226womenfoundrapidtestresultgrouphadsmallbutsignificantreduction
inaverageanxietyduringwaitingperiod
1trialwith60womendidnotfindsignificantdifferencesinanxietybefore
amniocentesis,3daysafter(whenresultsofrapidtestdisclosed),or3weeksafter
(whenfullkaryotyperesultsdisclosed)
ratesoffetallossduetoinvasivegenetictestingvaryinsingletonandtwinpregnancies
estimatedprocedurerelatedmiscarriageriskbefore24weeksgestation
50/85
20/11/2015
DynaMed
0.11%foramniocentesisand0.22%forchorionicvillussampling
basedonsystematicreviewofobservationalstudies
systematicreviewof21studiesevaluatingriskofprocedurerelatedmiscarriagein
womenhavingamniocentesisorchorionicvillussampling
324pregnancylossesin42,716womenwithamniocentesisand207lossesin8,899
womenwithchorionicvillussamplingobserved
pooledrateofmiscarriagepriorto24weeksgestation
0.81%foramniocentesisvs.0.67%withoutinvasiveprocedure(notsignificant)
inanalysisof7studieswith181,373women
2.18%withchorionicvillussamplingvs.1.79%withoutinvasiveprocedure(not
significant)inanalysisof3studieswith46,287women
estimatedweightedpooledprocedurerelatedmiscarriageriskbefore24weeks
gestation
0.11%(95%CI0.04%to0.26%)foramniocentesis
0.22%(95%CI0.71%to1.16%)forchorionicvillussampling
ReferenceUltrasoundObstetGynecol2015Jan45(1):16
intwinpregnancy,midtrimestergeneticamniocentesismayincreaseriskof
fetallossbyabout1%,whileriskwithfirsttrimesterchorionicvillussampling
isuncertain
basedonsystematicreviewofobservationalstudies
systematicreviewofstudiesevaluatingpregnancylossafterfirsttrimesterchorionic
villussampling(CVSat914weeksgestation)orgeneticamniocentesis(at1422
weeksgestation)inwomenwithtwinpregnancy
norandomizedtrialsidentified,22cohortstudiesorcaseseriesmetallinclusion
criteria
forgeneticamniocentesis
overallrateofpregnancylosswas3.1%(95%CI1.8%4.6%)inanalysisof4
caseseries
amniocentesisassociatedwithincreasedpregnancylosscomparedtono
amniocentesis(riskratio1.81,95%CI1.023.19)inanalysisof4studieswith
2,923women
forCVS
overallrateofpregnancylosswas3.8%(95%CI2.5%5.5%)inanalysisof4
caseseries
nosignificantdifferenceinoverallfetallosscomparingchorionicvillussamplingto
nochorionicvillussamplinginanalysisof2studieswith976women(riskratio
0.87,95%CI0.51.51)
nosignificantdifferencesinoverallfetallossafterCVScomparing
transabdominaltotranscervicalapproachinanalysisof2studies(riskratio
2.08,95%CI0.735.91)
singleneedlingsystemtodoubleneedlingsysteminanalysisof2studies
51/85
20/11/2015
DynaMed
singleuterineentryvs.doubleuterineentryin1study
allanalyseslimitedbywideconfidenceintervals
ReferenceUltrasoundObstetGynecol2012Aug40(2):128fulltext
amniocentesisdoesnotappeartobeassociatedwithsignificantincreasein
mothertochildtransmissionofHIV1
basedoncohortstudy
9,302womenwithHIV1infectionfollowedforrateofmothertochildHIVtransmission
with166amniocentesesperformedamongHIV1infectedwomenwithsingleton
pregnancies
amniocentesisperformedin1.8%
nomaternalchildtransmissionoccurredinwomentakinghighlyactiveantiretroviral
therapy(HAART)whohadamniocentesis
comparingmothertochildtransmissionofHIVwithamniocentesisvs.without
inwomennottakingHAART25%vs.16.2%(notsignificant)
inwomentakingmonotherapyorcombinationtherapy6.1%vs.3.3%(not
significant)
ReferenceAmJObstetGynecol2009Feb200(2):160e1
techniquemodification
aspirationcannulamayincreasepainandinadequatesampleretrieval
comparedtosmallforcepsinwomenhavingtranscervicalchorionicvillus
sampling(level2[midlevel]evidence),butinsufficientevidencetosupport
changeinpracticeforchorionicvillussamplingtechniques
systematicreviewof7randomizedtrialscomparingdifferentinstrumentsor
techniquesforchorionicvillussamplingin757pregnantwomen
alltrialshad1oftheselimitations
lackofblinding
fortranscervicalapproach
comparingaspirationcannulatosmallforceps
moderatetoseverepainin29.6%withaspirationcannulavs.15.3%with
smallforceps(p=0.02,NNH7)in1trialwith196women
aspirationcannulaassociatedwithincreaseininadequatesampleretrievalin
analysisof2trialswith319women
nosignificantdifferencesintotalpregnancylossandterminationfor
aneuploidyin1trialwith200women
portexcannulalesseffectivethansilver,malleable,andaluminumcannulasin
singletrials
nosignificantdifferencescomparingmalleablestainlesssteelcannulavs.
aluminumcannulain1trialwith50women
fortransabdominalapproach
52/85
20/11/2015
DynaMed
standardsyringewithhandgripdevicesignificantlyreducedneedforsecond
needleinsertion,buthadnosignificanteffectonpain,meanweightoftissue
obtained,orfetallosswithnormalkaryotypein1trialwith200women
standardsyringehaddecreasedmeanweightoftissueobtainedbutno
significantdifferenceintotalpregnancylossvs.fixedpistonsyringeneedle
techniquesin1trialwith85women
ReferenceCochraneDatabaseSystRev2013Jan31(1):CD000114
techniquemodificationsdonotappeartoaffectoutcomesforamniocentesis
orchorionicvillussampling
systematicreviewof5randomizedtrialsevaluatingtechniquemodificationsfor
amniocentesisorchorionicvillussamplingin1,049pregnantwomenat>15weeks
gestation
alltrialshadunclearallocationconcealmentand/orlackofblinding
foramniocentesis
nosignificantdifferenceinmiscarriagerateorpretermlaborcomparing
prophylacticintramuscularprogesteronevs.notreatmentin1trialwith584
women
nosignificantdifferencesinratesofdrytapandbloodytapcomparing
prophylactictocolysisvs.placeboin1trialwith69women
improvedamnioticfluidcollectionwithultrasoundguidedvs.palpationguided
procedurein1trialwith98women
forchorionicvillussampling(CVS)
prophylactictocolysisreducedriskofcontractionsbutdidnothavesignificant
effectonvaginalbleedingorpregnancylossin1trialwith102womenhaving
transcervicalCVS
continuousvacuumaspirationincreasedneedforsecondneedleinsertionanddid
notaffectmedianvillussamplesizecomparedtodiscontinuousvacuum
aspirationin1trialwith200womenhavingtransabdominalCVS
ReferenceCochraneDatabaseSystRev2012Aug15(8):CD008678
analgesiamaynotreducepainduringamniocentesis(level2[midlevel]
evidence)
basedonCochranereviewoftrialswithinadequatepowertoruleoutbenefit
systematicreviewof5randomizedandquasirandomizedtrialsevaluatinganalgesia
duringamniocentesisorchorionicvillussamplingin805pregnantwomen
notrialsfoundevaluatinganalgesiaduringchorionicvillussampling
heterogeneityininterventionsandtrialprotocolsprecludedmetaanalysistrialshad
inadequatepowertoruleoutbenefitofinterventions
nosignificantdifferenceinpainscorescomparing
infiltrativelocalanesthesiavs.noanesthesiabeforeamniocentesisin2trialswith
423womentotal
53/85
20/11/2015
DynaMed
lightlegrubbingvs.nointerventionduringamniocentesisin1trialwith200women
subfreezingcomparedvs.roomtemperatureneedlesduringamniocentesisin1trial
with62women
lidocaineprilocaineanalgesiccreamvs.placebocreambeforeamniocentesisin1
trialwith120women
Decisionsupport:
interactiveprenataltestingdecisiontoolreportedtoresultinmoreinformed
genetictestingdecisionmakingcomparedtoviewingstandardinformation
booklet(level3[lackingdirect]evidence)
basedonrandomizedtrialwithoutclinicaloutcomes
496EnglishorSpanishspeakingwomenat20gestationrandomizedtoview
interactiveprenataltestingdecisiontoolvs.CaliforniaDepartmentofHealthServices'
educationalbooklet
comparedtotheeducationalbookletgroup,interactivetoolgrouphad
higherknowledgescores(79.5%vs.64.9%,p<0.001,NNT7)
morecorrectestimatedriskofprocedureassociatedmiscarriage(64.9%vs.48.1%,
p=0.002,NNT6)
morecorrectestimatedriskofcarryingafetuswithDownSyndrome(63.5%vs.
15.1%,p<0.001,NNT2)
higherdegreeofsatisfactionwithgenetictestingdecisionintervention(p<0.001)
higherdegreeofdecisioncertainty(p<0.001)
ReferenceObstetGynecol2009Jan113(1):53
AntenatalFetalSurveillance
Indicationsandtechniquesforantenatalfetalsurveillance:
goalofantenatalfetalsurveillanceistopreventfetaldeathbyidentifyingsuspectedfetal
compromise(3)
SocietyofObstetriciansandGynecologistsofCanada(SOGC)andBritishColumbia
PerinatalHealthProgram(BCPHP)recommendationsforantenatalfetalmonitoring
considerfetalmonitoringforcertainmaternalconditions,including
antiphospholipidantibodysyndrome
poorlycontrolledhyperthyroidism
hemoglobinopathies(suchashemoglobinSS,SC,orSthalassemia)
cyanoticheartdisease
systemiclupuserythematosus(SLE)
chronickidneydisease
diabetesmellitustype1
hypertensivedisorders
morbidobesity
advancedmaternalage
54/85
20/11/2015
DynaMed
caraccidentduringpregnancy
considerfetalmonitoringforcertainpregnancyrelatedconditions,including
pregnancyinducedhypertension
antenatalhemorrhage
pretermprematureruptureofmembranes(PPROM)
decreasedfetalmovement
poorlycontrolledormedicallytreatedgestationaldiabetesmellitus(GDM)
oligohydramnios
intrauterinegrowthrestriction(IUGR)
prematurity
posttermpregnancy
isoimmunization
previousfetaldemise(unexplainedorrecurrentrisk)
breechpresentation
monochorionicmultiplegestationwithsignificantgrowthdiscrepancy
useofassistedreproductivetechnologies
ReferenceSOGCandBCPHPconsensusguidelinesonfetalhealthsurveillance(J
ObstetGynaecolCan2007Sep29(9Suppl4):S3),correctioncanbefoundinJObstet
GynaecolCan.2007Nov29(11):909,commentarycanbefoundinJObstetGynaecol
Can2007Dec29(12):972authorreply972
antenatalfetalsurveillancetechniquesinclude(3)
maternalperceptionoffetalmovement
contractionstresstest(CST)
nonstresstest(NST)
biophysicalprofile(BPP)ormodifiedBPP
umbilicalarteryDopplervelocimetry
additionofmanualfetalmanipulationduringtestsoffetalwellbeinghas
limitedevidencetoguidepractice
systematicreviewof4randomizedtrialsevaluatingmanualfetalmanipulationin
conjunctionwithtestsoffetalwellbeingin1,280pregnantwomen
durationandtechniqueofinterventionshadconsiderablevariation
resultsfornonreactiveelectronicfetalheartratepattern(cardiotocography)andtime
toachievereactiveresultsbothlimitedbysignificantheterogeneity
comparingmanualfetalmanipulationtomockornostimulation,nosignificant
differencesin
nonreactivecardiotocographyinanalysisof2trialswith1,098women,results
limitedbysignificantheterogeneity
testingtimetoachievereactiveresultinanalysisof2trialswith560women,results
limitedbysignificantheterogeneity
ReferenceCochraneDatabaseSystRev2013Dec7(12):CD003396
55/85
20/11/2015
DynaMed
seealsoFetalmonitoringduringlabor
Timingandfrequencyofantenatalfetalsurveillance:
timingofantenatalfetaltesting(3)
timingofantenatalfetalsurveillancevariesbyprognosisforneonatalsurvival,riskof
fetaldeath,severityofmaternaldisease,andpotentialforiatrogenicprematurity
complicationssecondarytofalsepositivetestresults
startingfetalsurveillanceat32weeksgestationisappropriateformostpregnancies
(ACOGLevelC)
earliersurveillance,beginningatagestationalagewhendeliverycouldbeconsidered,
maybeindicatedinpregnancieswithmultipleorespeciallyworrisomehighrisk
conditions(ACOGLevelC)
frequencyoftesting(3)
idealfrequencyoftestingnotdeterminedandshouldbebasedonindividualindications
andclinicianjudgement
ifindicationfortestingisnotpersistent(suchasasingleepisodeofdecreasedfetal
movementfollowedbyreassuringtestinuncomplicatedpregnancy),additionaltesting
notnecessary
ifindicationfortestingpersists,repeattestperiodicallyuntildelivery(ACOGLevelC)
ifmaternalconditionisstableandtestresultsarereassuring,fetalwellbeingtests
aretypicallyrepeatedatweeklyintervals
inpresenceofhighriskconditions,morefrequenttestingmaybeindicatedbut
optimalfrequencynotestablished
mostgrowthrestrictedfetusescanbeevaluatedwithserialultrasoundevery34
weeks(ultrasoundshouldnotbeperformedmoreoftenthanevery2weeksdueto
potentialforerror)
Fetalmovement:
Guidelinesonfetalmovement:
RoyalCollegeofObstetricianandGynaecologists(RCOG)guidelinesonfetalmovements
generalinformationonfetalmovement
womenfeelfetalmovementat1620weeksgestation
frequencyoffetalmovementstendtoplateauat32weeksgestationbutdoesnot
decrease
nouniversallyagreeddefinitionofreducedfetalmovement
assessingfetalmovement
assessfetalmovementbysubjectivematernalperceptionofmovement(RCOG
GradeC)
advisewomentobeawareoffetalmovementthroughtheonsetoflaborand
reportdecreaseorcessationoffetalmovement(RCOGGPP)
advisewomentobeawareofneonate'sindividualpatternofmovementand
reportreductionorcessationofmovementafter28weeksgestation(RCOG
56/85
20/11/2015
DynaMed
GradeC)
advisewomennoticingasuddenchangeinfetalactivity,orwomenwithother
riskfactorsforstillbirth,tobeclinicallyevaluated(RCOGGPP)
insufficientevidencetorecommendformalfetalmovementcountingwithaspecified
alarmlimits(RCOGGradeB)
advisewomenwhoareunsureifthereisreducedfetalmovementafter28weeks
gestationtolieontheirleftsideandfocusonfetalmovementfor2hoursifthey
feel<10movementsduringthistimetheyshouldcontactcareprovideror
maternityunit(RCOGGradeC)
instructingwomentomonitorfetalmovementmaybeassociatedwithincreased
maternalanxiety(RCOGLevel2+)
considerevaluationiffetalmovementhasneverbeenfeltby24weeksgestation
(RCOGGPP)
initialassessmentofreportedreducedfetalmovement
advisewomennottowaituntilthenextdayforassessmentoffetalwellbeing
(RCOGGPP)
assessforriskfactorsforstillbirthandfetalgrowthrestriction(RCOGGradeB)
factorsassociatedwithincreasedriskofstillbirthinclude
currentpregnancyfactorssuchas
multipleepisodesofreducedfetalmovement
fetalgrowthrestriction
placentalinsufficiency
congenitalmalformations
firstpregnancy
maternalfactorssuchas
hypertension
diabetes
extremesinmaternalage
smoking
obesity
racial/ethnicandgeneticfactors
historyofstillbirthorfetalgrowthrestrictioninpreviouspregnancies
physicalexamshouldinclude
auscultationoffetalheartrateusinghandheldDopplerdevicetoexcludefetal
death(RCOGGradeB)ifnodeviceisavailablewherethewomenpresents,
patientshouldbereferredimmediatelytomaternityunit(RCOGGradeB)
assessmentoffetalsize(byabdominalpalpationorultrasound)todetectfetuses
thataresmallforgestationalage
reassurepatientifthereisnotreducedfetalmovements,nootherriskfactorsfor
stillbirthandfetalheartratepresentonauscultationbutevaluationadvisedifpatient
remainsconcerned(RCOGGradeC)
57/85
20/11/2015
DynaMed
ifhistoryconfirmsdecreasedfetalmovementinpregnancy28weeksgestation,
excludefetalcompromisewithcardiotocography(nonstresstest)(RCOGGradeB)
ultrasoundevaluation
performultrasoundassessmentinpatientspresentingwithreducedfetalmovement
28weeksgestationineitherofthefollowingsituations(RCOGGradeB)
ifcardiotocographyisnormalbutperceptionofreducedfetalmovementpersists
ifthereareanyadditionalriskfactorsforfetalgrowthrestrictionorstillbirth
ultrasoundevaluationshouldincludemeasurementofabdominalcircumference
and/orestimatedfetalweight,andassessmentofamnioticfluidvolume(RCOG
GradeC)
assessfetalmorphologyifitwasnotassessedinpriorstudiesaslongasthe
patienthasnoobjectionstothisbeingperformed(RCOGGradeA)
theremaybearolefortheuseofbiophysicalprofileintheevaluationofreducedfetal
movement(RCOGGradeB)
ifnormalevaluationaftersingleepisodeofreducedfetalmovement
reassurepatientthat70%ofpregnancieswithoneepisodeofreducedfetal
movementareuncomplicated(RCOGGradeC)
nodatasupportsformalfetalmovementcountinginpatientswhohadperceived
reducedfetalmovementswhohadnormalinvestigations(RCOGGradeC)
advisepatienttoreportifepisodeofreducedfetalmovementrecurs(RCOGGPP)
ifpatientpresentswithrecurrentepisodesofdecreasedfetalmovement
excludepredisposingcausesofreducedfetalmovement(RCOGGradeC)
performultrasoundevaluationaspartoftheinvestigation(RCOGGradeB)
patientspresenting2timeswithreducedfetalmovementmaybeatincreased
riskofpoorperinataloutcomes(RCOGLevel2)
ReferenceRCOGGreentopGuideline57ReducedFetalMovements2011Feb
Fetalmovementassessmentasscreeningtool:
dailyfetalmovementassessmentnotnecessary,butwomenshouldbeawareofany
decreasesinfetalactivity(3)
optimalnumberoffetalmovementsandtheidealdurationforcountingmovementshas
notbeendefined(3)
approachestofetalmovementassessmentinclude(3)
advisewomantolayonsideandcountdistinctfetalmovements
10distinctmovementsinperiodofupto2hoursconsideredreassuring
meantimeintervalto10movementsreportedtobe20.9minutes
countfetalmovementsfor1hour3times/week(countconsideredreassuringifit
equalsorexceedswoman'spreviouslyestablishedbaselinecount)
inabsenceofreassuringcount,additionalfetalassessmentisrecommended(3)
insufficientevidencetorecommendfetalmovementcountingforassessmentof
fetalwellbeinginpregnantwomen
58/85
20/11/2015
DynaMed
systematicreviewof4randomizedtrialsofformalfetalmovementcountingin71,370
women(1clusterrandomizedtrialincluded68,654women)
2trialscompareddifferenttypesofcounting
1trialcomparedformalfetalmovementcountingvs.countingwithoutformal
instruction
1trialcomparedformalfetalmovementcountingvs.hormoneanalysis
formalfetalmovementcountingassociatedwithfewerantenatalhospitalvisits
(relativerisk0.26,95%CI0.20.35)butmoreneonateswith5minuteApgarscores<
7(relativerisk1.72,95%CI1.012.93)comparedtohormoneanalysisin1trial
Cardiff'counttoten'methodassociatedwithhighercompliancethanformalfetal
movementcounting
notrialscomparedfetalmovementcountingvs.nofetalmovementcounting
Referencesystematicreviewlastupdated2006Oct6(CochraneDatabaseSystRev
2007Jan24(1):CD004909)
insufficientevidencetoevaluateinterventionsformanagementofdecreased
fetalmovement
systematicreviewofrandomizedorquasirandomizedtrialsevaluatinganyintervention
formanagementofdecreasedfetalmovement
norandomizedtrialsevaluatingmanagementofdecreasedfetalmovementmet
inclusioncriteria13trialsevaluatedwomenwithriskfactorsforfetalcompromise
dataavailableforsubgroupof28womenwithreporteddecreasedfetalmovement
from1trialnosignificantdifferenceinperinatalmortality/morbidityorcesarean
sectionratecomparingmodifiedbiophysicalprofilefollowingvibroacousticstimulation
vs.mockstimulation
ReferenceCochraneDatabaseSystRev2012Apr18(4):CD009148
Fetalheartratetesting:
Nonstresstest:
nonstresstest(NST)basedonpremisethatfetalheartrate(FHR)willtemporarily
acceleratewithfetalmovementifnotacidoticorneurologicallydepressed(3)
heartratereactivityconsideredagoodindicatorofnormalfetalautonomicfunction
lossofreactivityisoftenassociatedwithfetalsleepcycle,butmaybeduetoany
causeofcentralnervoussystemdepression,includingfetalacidemia
performNSTwithpatientineithersemiFowlerposition(sittingwithheadelevates30
degrees)orlateralrecumbentposition(3)
monitorFHRwithexternaltransducer,andobservetracingforFHRaccelerationsthat
peak(butdonotnecessarilyremain)at15beats/minuteabovebaselineandlast15
secondsfrombaselinetobaseline
conductNSTfor20minutes(maybenecessarytomonitortracing40minutesto
accountforvariationsinfetalsleepwakecycle)
vibroacousticstimulationmaytriggerFHRaccelerationstohelpdeterminefetalwellbeing
59/85
20/11/2015
DynaMed
vibroacousticstimulationisperformedwithdevicepositionsonmaternalabdomenand
stimulusappliedfor12seconds (3)
ifnoresponse,repeatvibroacousticstimulationupto3timesforprogressivelylonger
durations(upto3seconds)(3)
reportedtoreducefrequencyofnonreactiveNSTsbyabout40%andoveralltesting
timebyabout7minuteswithoutcompromisingdetectionoffetalacidemia(3)
fetalvibroacousticstimulationmayreducenonreactiveantenatal
cardiotocography(level2[midlevel]evidence)
basedonCochranereviewoftrialswithunclearornoblinding
systematicreviewof12randomizedtrialsevaluatingfetalvibroacousticstimulation
inconjunctionwithtestsoffetalwellbeingin6,822pregnantwomen
comparingfetalvibroacousticstimulationtomockornostimulation
fetalvibroacousticstimulationassociatedwith
reducednonreactiveantenatalcardiotocographyinanalysisof9trialswith
4,817women
riskratio0.62(95%CI0.480.81)
NNT1644withnonreactiveantenatalcardiotocographyin12%ofmockor
nostimulationgroup
shortercardiotocographytestingtime(meandifference6.93minutes,95%CI
12.09to1.76minutes)inanalysisof3trialswith2,295women,results
limitedbysignificantheterogeneityineffectsize
nosignificantdifferenceinperinatalmortalityinanalysisof5trialswith4,107
neonates(25totaldeathsreported)
nosignificantdifferenceinnonreactivecardiotocographycomparingfetal
vibroacousticstimulationtomanualstimulationin1trialwith300women
NSTresultscharacterizedasreactiveornonreactive(3)
mostcommondefinitionofreactive(normal)NSTis2FHRaccelerationswithina20
minuteperiod
nonreactiveNSTcharacterizedbyinsufficientFHRaccelerationsover40minuteperiod
NSTofnormalpretermfetusisoftennonreactive
upto50%ofNSTsreportedtobenonreactivefrom2428weeksgestation
about15%ofNSTsreportedtobenonreactivefrom28weeks32weeksgestation
variabledecelerationsreportedinupto50%ofNSTs
nonrepetitive,briefvariabledecelerationsnotassociatedwithfetalcompromiseor
needforintervention
repetitivevariabledecelerations(3in20minutes)maybeassociatedwith
increasedriskofcesareandeliveryfornonreassuringintrapartumFHRpattern
FHRdecelerationsthatpersist1minuteassociatedwithincreasedriskfor
cesareandeliveryandfetaldemise,anddecisiontodelivershouldbebasedon
benefitsofdeliveryoutweighthepotentialrisksofexpectantmanagement
60/85
20/11/2015
DynaMed
useoflessstringentfetalheartrateaccelerationcriteriamayreducetimeto
reactivenonstresstestwithsimilarclinicaloutcomesinwomenat32
gestationalweekswithsingletonhighriskpregnancy(level2[midlevel]
evidence)
basedonrandomizedtrialwithoutintentiontotreatanalysis
143womenwithsingletonhighriskpregnancyreferredfornonstresstestingat32
gestationalweekswererandomizedto1of2fetalheartrateaccelerationcriteria
2episodesin20minutesof10beats/minutefor10seconds(10X10)
2episodesin20minutesof15beats/minutefor15seconds(15X15)
5%didnotcompletetrialandwereexcludedfromanalyses
mediantimetoreactivenonstresstest37.3minuteswith10X10groupvs.41.3
minuteswith15X15group(p=0.04)
nosignificantdifferencesinperinataloutcomesofbirthweight,gestationalageat
delivery,lowApgarscoresat1or5minutes,congenitalanomalies,orneonatal
intensivecareunitadmissions,althoughstudynotadequatelypoweredtoassess
safetyoutcomes
ReferenceAmJObstetGynecol2012Oct207(4):311.e1
Contractionstresstest:
contractionstresstest(CST)isbasedonresponseoffetalheartrate(FHR)touterine
contractions (3)
underlyingpremiseisthatfetaloxygenationwillbeworsenedbyuterinecontractions
intermittentworseningofoxygenationleadstolatedecelerationsinFHRpatterns
contractionsmayalsocreatepatternofvariabledecelerationssecondarytofetal
umbilicalcordcompression(maybeassociatedwitholigohydramnios)
CSTconsideredsafeandeffectiveforinvestigatingFHRnonreactivityinpreterm
gestations
contraindicationstoCSTincludeconditionsthatarecontraindicationstolaboror
vaginaldelivery
performCSTwithpatientinlateralrecumbentposition(3)
simultaneouslyrecordFHRanduterinecontractionswithexternalfetalmonitor
3contractionspersistingfor40secondseachin10minuteperiodconsideredan
adequateuterinecontractionpattern
if<3contractionsof40secondsdurationin10minutes,performuterinestimulation
uterinestimulationmayincludenipplestimulationorIVoxytocin
nipplestimulationusuallysuccessfulforinducingadequatecontractionpatternand
takesabouthalfthetimerequiredforIVoxytocin
CSTresultsarecategorizedas (3)
negativenolateorsignificantvariabledecelerations
positivelatedecelerationsafter50%ofcontractions(evenifcontractionfrequency
is<3in10minutes)
equivocal/suspiciousintermittentlatedecelerationsorsignificantvariable
61/85
20/11/2015
DynaMed
decelerations
equivocalFHRdecelerationsinpresenceofcontractionsmorefrequentthanevery2
minutesorlasting>90seconds
unsatisfactory<3contractionsin10minutesoruninterpretabletracing
Additionalconsiderations:
maternalglucoseadministrationmaynotreducenonreactivecardiotocography
(level2[midlevel]evidence)
systematicreviewof2randomizedtrialsevaluatingmaternal(oralorIV)glucose
administrationinconjunctionwithtestsoffetalwellbeingin708pregnantwomen
nosignificantdifferenceinnonreactivecardiotocographycomparingmaternalglucose
administrationtocontrol(oddsratio0.93,95%CI0.661.3)inanalysisofbothtrials
ReferenceCochraneDatabaseSystRev2012Sep12(9):CD003397
antenatalcardiotocographyinwomenatincreasedriskofcomplicationsdoes
notappeartodecreasepreventableneonatalormaternaloutcomes(level2
[midlevel]evidence)
basedonCochranereviewwithinadequatepowertoruleoutclinicallyimportant
differences
systematicreviewof6randomizedorquasirandomizedtrialsevaluatingantenatal
cardiotocographyin2,105pregnantwomen
alltrialsincludedonlywomenatincreasedriskofcomplications
analyseshadinadequatepowertodetectdifferencesinpotentiallypreventable
perinatalmortality
nosignificantdifferenceinanyoutcomecomparingtraditionalcardiotocographyvs.no
cardiotocographybutwideconfidenceintervalscannotruleoutclinicallyrelevant
differences
comparingcomputerizedcardiotocographytotraditionalcardiotocography
computerizedcardiotocographyassociatedwithsignificantlyreducedperinatal
mortalityinanalysisof2trialswith469patients
riskratio0.2(95%CI0.040.88)
NNT26209withperinatalmortalityin4%ofcontrolgroup
nosignificantdifferencesinpotentiallypreventableperinatalmortality,cesarean
sections,orothersecondaryoutcomes
notrialsidentifiedcomparingcomputerizedcardiotocographyvs.nocardiotocography
Biophysicalprofile(BPP)ormodifiedBPP:
biophysicalprofile(BPP)(3)
comprisedof5componentswitheachcomponentassigned2pointsifpresent,or0
pointsifnotpresent
ultrasoundassessmentof
fetalbreathingmovements(1episodesofrhythmicfetalbreathingmovements
62/85
20/11/2015
DynaMed
withduration30secondswithin30minutes)
fetalmovement(3discretebodyorlimbmovementswithin30minutes)
fetaltone(1episodesofextensionoffetalextremitywithreturntoflexion,or
opening/closingofahand)
amnioticfluidvolume(singledeepestverticalpocket>2cm)
nonstresstest(maybeomittedifresultsofother4componentsarenormal)
scoringoutcomes
8or10considerednormal
6consideredequivocal
4consideredabnormal
modifiedBPP(3)
combinesnonstresstest(NST)(shorttermindicatoroffetalacidbasestatus)with
amnioticfluidvolumeassessment(indicatoroflongtermplacentalfunction)
resultsconsiderednormalifNSTisreactiveandamnioticfluidvolumeis>2cmin
deepestverticalpocket
resultsconsideredabnormalifeitherof
NSTisnonreactive
amnioticfluidvolumeindeepestverticalpocketis2cm(indicating
oligohydramnios)
Umbilicalarterydopplervelocimetry:
umbilicalarteryDopplervelocimetry(3)
noninvasivetechniqueevaluatingumbilicalflowvelocitywaveforminfetus
normalresultscharacterizedbyhighvelocitydiastolicflow
growthrestrictedfetuseshavedecreasedumbilicalarterydiastolicflow(diastolic
flowmaybeabsentorreversedinseverecases)
commonlymeasuredflowindicesinclude
systolictodiastolicratio(S/D)
resistanceindex(SD/S)
pulsatilityindex(SD/A)
usefulnessmaybelimitedtopregnanciescomplicatedbyintrauterinegrowthrestriction
(IUGR)asnoevidencesupportsitsusefordeterminingfetalwellbeinginfetuswith
normalgrowth
ingrowthrestrictedfetuses,useofumbilicalarteryDopplervelocimetryinaccordance
withstandardfetalsurveillance(nonstresstestsand/orBPPs)associatedwith
improvedoutcomes(ACOGLevelA)
ifusedfortimingofdeliverydecisionmaking,alsoconsiderresultsofotherfetal
testingandcarefulmonitoringofmaternalstatus
uterinearteryDopplerandplacentalultrasoundmayhelpdetermineriskof
adversepregnancyoutcomeinwomenwithelevatedalphafetoproteinand
humanchorionicgonadotropin(level2[midlevel]evidence)
basedonprognosticcohortstudy
63/85
20/11/2015
DynaMed
50singletonpregnancieswithelevatedalphafetoprotein(AFP)andhumanchorionic
gonadotropin(hCG)onmaternalserumscreeningandnormalfetalanatomical
ultrasoundhadplacentalultrasoundanduterinearteryDopplerat1923weeks
gestation
abnormalitiesinplacentalultrasoundanduterinearteryDopplerpredicted
pretermdeliveryat<32weeksgestation(24cases)with75%sensitivity,75%
positivepredictivevalue,positivelikelihoodratio3.3
intrauterinefetaldeath(12cases)with100%sensitivity,50%positivepredictive
value,positivelikelihoodratio3.1
intrauterinegrowthrestriction(17cases)with94%sensitivity,67%positive
predictivevalue,positivelikelihoodratio3.9
ReferenceAmJObstetGynecol2006Mar194(3):821
Managementofabnormalresultsonantenatalfetalassessment:
considerretestingwomenwithabnormaltestresultsasantepartumfetalsurveillance
testsareassociatedwithhighfalsepositivesandlowpositivepredictivevalues (3)
someacuteconditions(suchasdiabeticketoacidosisorpneumoniawithhypoxemia)may
presentwithabnormaltestresultswhichwilltypicallynormalizeasconditionimproves,
anddonotrequireadditionalmanagementorretesting(3)
maternalreportsofdecreasedfetalmovement(3)
evaluatematernalreportsofdecreasedfetalmovementusingnonstresstest(NST),
contractionstresstest(CST),biophysicalprofile(BPP),ormodifiedBPP
ifabnormalnonstresstestormodifiedbiophysicalprofile(BPP),performcontraction
stresstest(CST)orBPP(ACOGLevelB)
ifBPPscoreis6outof10
performadditionaltestingandconsiderdeliveryif37weeksgestation
repeatBPPin24hoursif<37weeksgestation
ifrepeatBPPscoreis4,deliveryusuallyindicated
inpregnancies<32weeksgestation,basemanagementonindividual
circumstances(extendedmonitoringmaybeappropriate)
ifBPPscore<4,deliveryisrecommended
oligohydramnios (3)
definedassingledeepestverticalpocketofamnioticfluid2cm(notcontaining
umbilicalcordorfetalextremities)andamnioticfluidindex5cm
useofsingledeepestpocket(asopposedtoamnioticfluidindex)todiagnose
oligohydramniosmayreduceunnecessaryinterventionswithoutincreasingadverse
perinataloutcomes(ACOGLevelA)
assessformembraneruptureasitcanleadtoreducedamnioticfluidvolume
deliveryat3637weeksgestationrecommendedifisolated,persistentoligohydramnios
andotherwiseuncomplicatedpregnancy(ACOGLevelC)
if<36weeksgestationwithintactmembranes,basedecisiontoproceedwith
expectantmanagementordeliveryongestationalageandmaternalandfetalcondition
64/85
20/11/2015
DynaMed
(ACOGLevelC)
ifdeliverynotperformed
performfollowupamnioticfluidvolumemeasurement,nonstresstests,andfetal
growthassessment
followupamnioticfluidvolumeassessmentnotnecessaryifoligohydramniosisdue
torupturedmembranes
ifabnormalfetaltestresultandnoobstetriccontraindications,considerinductionoflabor
withcontinuousmonitoringoffetalheartrateandcontractions(ACOGLevelC)(3)
intrapartumfetalmonitoringrecommendedduringlaboranddelivery,evenincaseswith
recentnormalantenatalfetaltestresults (3)
ImmunizationandChemoprophylaxis
AmericanCollegeofObstetriciansandGynecologists(ACOG)adoptedtheAdvisory
CommitteeonImmunizationPractices(ACIP)recommendationsforvaccinationin
pregnancy
influenzavaccinerecommendedforallwomenwhoareorwillbepregnantduring
influenzaseason(OctoberMayinUnitedStates)
influenzavaccinationfrominactivated/noninfectiousvirusesconsideredsafeatany
gestationalage
preservativefreevaccinesmaybeofferedtowomenwithhypersensitivitytoeggsor
vaccinecomponents
nasalsprayinfluenzavaccines(madefromliveattenuatedvirus)notrecommended
inpregnancybutmaybeusedpostpartum
offervaccinationtohouseholdcontactsofpregnantwomen
ReferenceACOGcommitteeopinionno.608oninfluenzavaccinationduring
pregnancy(ObstetGynecol2014Sep124(3):648)
tetanus,diphtheria,andpertussis(Tdap)vaccinerecommendedforallpregnant
womenduringeachpregnancy
idealtimeforvaccinationisbetween2736weeksgestationforantibodyresponse
andpassiveimmunitytofetus,butvaccinemaybeadministeredanytimeduring
pregnancy
ifnotadministeredduringpregnancy,administerTdapimmediatelypostpartum
reasonstovaccinateearlierinpregnancymayinclude
ongoingepidemics(immunizewomenlivinginregionswithpertussisepidemicsas
soonaspossibleinaccordancewithrecommendationsfornonpregnantadults)
woundmanagement
aspartofstandardcareforwoundmanagement,tetanustoxoidcontaining
vaccinerecommendedinpregnantwomanif5yearshavepassedsince
previoustetanusanddiphtheria(Td)vaccination
ifTdboostervaccinationisindicatedforacutewoundmanagement,
administerTdapregardlessofgestationalage
donotrevaccinatewithTdapinsamepregnancyifalreadyvaccinatedinfirst
65/85
20/11/2015
DynaMed
orsecondtrimester
unknownorincompletevaccinationagainsttetanusanddiphtheria(Td)
3vaccinationscontainingtetanusandreduceddiphtheriatoxoids
recommendedat0,4weeks,and612months
Tdapshouldreplace1doseofTd,preferablyafter20weeksgestation
iftheyarenotcurrentwiththeirvaccinations,offerTdapvaccinetofamilymembers
ofpregnantwomenandthosewhowillbecaringforneonateatleast2weeks
beforeplannedinfantcontact
ReferenceACOGcommitteeopinionno.566onimmunizationandpregnancy
(ObstetGynecol2013Jun121(6):1411)
about50%ofinsuredpregnantwomenreceivedTdaporinfluenzavaccines(with
35%ofwomenreceivingbothvaccines)asrecommendedbyACIPguidelinesincohort
studyof12,089womeninWisconsin,UnitedStatesduringNovember2013March2014
(MMWRMorbMortalWklyRep2015Jul1764(27):746
EBSCOhostFullTextfull
text)
postpartumvaccinations
inwomenwhoarenotimmunetorubella,offervaccinationinpostpartumperiodto
preventcongenitalrubellasyndromeinsubsequentpregnancies (1,2)
offervaricellavaccinationpostpartumtoallpatientswhoareseronegativefor
immunoglobulinG(2)
influenzavaccinationinpregnancyassociatedwithdecreasedinfluenzalike
illnessinmothersandinfants,anddecreasedlaboratoryconfirmedinfluenzain
infants(level2[midlevel]evidence)
basedonsystematicreviewofmostlyobservationalstudies
systematicreviewof8studies(1randomizedtrial,7cohortstudies)evaluating
influenzavaccinationin182,820pregnantwomenand182,246neonates
nometaanalysisperformedduetoheterogeneityinmeasuresofassociationforsame
outcomebetweenstudies
7studiesevaluatedtrivalentinactivatedvaccine
comparedtocontrols,influenzavaccinationassociatedwith
significantlydecreasedinfluenzalikeillnessinmothers(2studies)andinfants(1
study)
significantlydecreasedlaboratoryconfirmedinfluenzaininfantsin2studies
nosignificantdifferencesin
acuteupperrespiratorytractinfectioninmothers(2studies)orinfants(1study)
influenzalikeillnesswithfever>38degreesC(100.4degreesF)inmothersand
infantsin1study
hospitalizationforinfluenzalikeillnessinmothers(1study)andinfants(4
studies)
ReferenceISRNPrevMed20132013:879493fulltext
3doseacceleratedhepatitisBvaccinationscheduleat0,1,and4months
66/85
20/11/2015
DynaMed
appearseffectiveandwelltoleratedinhighriskpregnantwomen(level2[mid
level]evidence)
200highriskpregnantwomenwhowerehepatitisBsurfaceantigennegativeat
presentationforprenatalcarehadhepatitisBvaccineat0,1,and4monthschedule
84%ofwomencompleted3dosevaccine
followingvaccination,seroconversion(hepatitisBsurfaceantigen10milliunits/mL)
was
56%after1dose(95%CI49%63%)
77%after2doses(95%CI71%83%)
90%after3doses(95%CI85%94%)
bodymassindex(BMI)inverselyassociatedwithseroconversionrates(p<0.001),but
therewasnosingleBMIabovewhichseroconversiondidnotoccur
noseriousadverseeffectsreported
reviewofvaccinationsforpregnantwomencanbefoundinObstetGynecol2015
Jan125(1):212
AdditionalConsiderations
Weightgaininpregnancy:
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendationsforobese
womenwhoarepregnantorplanningapregnancy
providepreconceptionassessmentandcounseling,includinginformationregarding
maternalandfetalcomplicationsofobesityinpregnancy,andencouragepatientto
beginaweightreductionprogram
measureheightandweightatinitialprenatalvisittodeterminebaselinebodymass
index(BMI),andreviewguidelinesforappropriateweightgainthroughoutpregnancy
offernutritionconsultationtoalloverweightorobesewomen,andencouragethemto
followanexerciseprogram(continuenutritionandexercisecounselingpostpartumand
priortoattemptinganotherpregnancy)
evaluatewomenwithhistoryofbariatricsurgeryforvitamindeficiencies,and
supplementasneeded
considerusinghigherdosesofpreoperativeantibioticsforcesareandelivery
prophylaxis
consideruseofsutureclosureofsubcutaneouslayeraftercesareandeliverytoreduce
riskforpostoperativewounddisruption
consideranesthesiologyconsultationearlyinlabor
encourageconsultationwithweightreductionspecialistpriortoattemptinganother
pregnancy
ReferenceACOGcommitteeopinionno.549onobesityinpregnancy(ObstetGynecol
2013Jan121(1):213)
67/85
20/11/2015
DynaMed
AmericanCollegeofObstetriciansandGynecologists(ACOG)adoptedtheInstituteof
Medicine's(IOM)weightgainrecommendationsforpregnancy
recommendedweightgainbyprepregnancyweightcategoryforwomenwithsingleton
pregnancies
underweight(BMI<18.5kg/m2)
recommendedtotalweightgain2840lbs
recommendedratesofweightgaininsecondandthirdtrimesters1lb/week
(meanrange11.3lbs/week)
normalweight(BMI18.524.9kg/m2)
recommendedtotalweightgain
2535lbsforsingletonpregnancies
3754lbsfortwinpregnancies
recommendedratesofweightgaininsecondandthirdtrimester1lb/week
(meanrange0.81lb/week)
overweight(BMI2529.9kg/m2)
recommendedratesofweightgaininsecondandthirdtrimester0.6lbs/week
(meanrange0.50.7lbs/week)
obese(BMI30kg/m2)
recommendedratesofweightgaininsecondandthirdtrimester0.5lbs/week
(meanrange0.40.6lbs/week)
ReferenceACOGcommitteeopinionno.548onweightgainduringpregnancy(Obstet
Gynecol2013Jan121(1):210)
planningapregnancy
providepreconceptionassessmentandcounseling,includinginformationregarding
maternalandfetalcomplicationsofobesityinpregnancy,andencouragepatientto
beginaweightreductionprogram
measureheightandweightatinitialprenatalvisittodeterminebaselinebodymass
index,andreviewguidelinesforappropriateweightgainthroughoutpregnancy
offernutritionconsultationtoalloverweightorobesewomen,andencouragethemto
followanexerciseprogram(continuenutritionandexercisecounselingpostpartumand
priortoattemptinganotherpregnancy)
evaluatewomenwithhistoryofbariatricsurgeryforvitamindeficiencies,and
supplementasneeded
considerusinghigherdosesofpreoperativeantibioticsforcesareandelivery
prophylaxis
68/85
20/11/2015
DynaMed
consideruseofsutureclosureofsubcutaneouslayeraftercesareandeliverytoreduce
riskforpostoperativewounddisruption
consideranesthesiologyconsultationearlyinlabor
encourageconsultationwithweightreductionspecialistpriortoattemptinganother
pregnancy
ReferenceACOGcommitteeopinionno.549onobesityinpregnancy(ObstetGynecol
2013Jan121(1):213)
patientswhoareoverweightorunderweighthaveincreasedriskforcomplications (1,2)
highprepregnancyBMIassociatedwithincreasedriskfor
gestationaldiabetes
hypertensivedisordersofpregnancy,includingpreeclampsia
labordystocia
laborinduction
cesareansection
woundinfection
antenatalvenousthromboembolism
anesthesiarelatedcomplications
lowprepregnancyBMIassociatedwithincreasedriskforanemiaandpretermbirth
organizedprogramofdietaryandlifestylecounselingmayreduceweightgainin
pregnancy(level2[midlevel]evidence)
basedonrandomizedtrialwithinadequatestatisticalpower
100pregnantwomenwerestratifiedbybodyweight(normal,overweight,orobese)
andrandomizedtodietaryandlifestylecounselingvs.routineprenatalcare
interventiongrouphaddietaryandlifestylecounselingbyregistereddieticianin
additiontoroutinecare
routinecareincludedphysicalexam,history,routinelaboratorytests,and
routineprenatalvisits
trialdidnotachievepredeterminedpowerasrecruitmentwasterminatedearly
secondarytotimerestrictionsinvolvedincompletingresidentialresearchproject(61
patientsineachtreatmentarmrequiredtoachieve80%power)
comparingdietaryandlifestylecounselingvs.routineprenatalcare
meanweightgain28.7lbsvs.35.6lbs(p=0.01)
cesareansectionduetofailuretoprogressin25%vs.58.3%(p=0.02,NNT3)
nulliparouswomengainedsignificantlymoreweightthanparouswomen(mean36.5
lbsvs.27.7lbs,p<0.01)
ReferenceObstetGynecol2009Feb113(2Pt1):305,commentarycanbefoundin
ObstetGynecol2009Jul114(1):173authorreply173
groupbasedweightmanagementprogrammayreducelargeforgestational
agenewbornsandgestationalweightgaininobesewomen(level2[midlevel]
evidence)
basedonrandomizedtrialwithoutattentioncontrol
69/85
20/11/2015
DynaMed
114obesewomen(meanage32years,meanBMI36.7kg/m2)at721gestational
weekswererandomizedto1of2interventions
groupbasedweightmanagementprogramonceweeklyuntildeliveryfocusingon
diet,exercise,behavioralselfmanagement,andcaloriegoals
singlesessionofdietaryadvicewithoutspecificfocusonweightmanagement
(control)
womenininterventiongroupattended2individualsessionsinfirstweekpriortogroup
sessions
comparinggroupbasedweightmanagementprogramvs.control
rateoflargeforgestationalagenewborn9%vs.26%(p=0.02,NNT6)
meanweightgainat34gestationalweeks5kg(11lbs)vs.8.4kg(18.5lbs)(p<
0.001)
meanweightchangeat2weekspostpartum2.6kg(5.7lbs)vs.+1.2kg(+2.6
lbs)(p<0.001)
neonatalbirthweight>90thpercentilein9%vs.26%(p=0.02)
nosignificantdifferencesinothermaternalorneonataloutcomes
ReferenceObesity(SilverSpring)2014Sep22(9):1989
Nutritioninpregnancy:
Foodandfoodborneillness:
counselpatientonpropernutrition,includingsupplementation,andevaluatepatientsfor
nutritionaldeficiencies (1,2)
encourageironabsorptionfromfoodsforallpregnantwomen(1)
dietaryguidelinesforpregnantwomen
additionalcalorierequirements/dayvarybytrimester
noadditionalcaloriesgenerallyneededinfirsttrimesterduetominimalweightgain
andnoincreaseinenergyexpenditure
about340additionalcalories/daygenerallyneededinsecondtrimester
about450additionalcalories/daygenerallyneededinthirdtrimester
ReferenceJNutr2003Jun133(6):1997Sfulltext
generalrecommendations (2)
washfruitsandvegetablesbeforeeating,andwashcuttingboards,dishes,utensils,
andhandsinhot,soapywateraftercontactwithunwashedproduceduetoriskof
ToxoplasmaandListeriacontamination
thoroughlyreheatleftoverfoodsbeforeconsumingduetoriskforListeria
contamination
limitcaffeineconsumptionto150300mg/day(about12cupsofcaffeinated
coffee)duetoassociationbetweenhighcaffeineconsumption,miscarriage,andlow
birthweightinobservationalstudies
avoidunpasteurizeddairyandsoftcheeses,suchasfeta,Brie,Camembert,blue
veinedcheeses,andMexicanquesofrescoduetoriskofToxoplasmaandListeria
contamination
70/85
20/11/2015
DynaMed
avoidraweggs,includingineggnogandcookiedough,duetoriskofsalmonella
contamination
artificialsweeteners
minimizeuseofsaccharinasmaycrossplacentaandremaininfetaltissue
useofaspartame,sucralose,andacesulfameKreportedtobesafe
meat
eatliverandliverproductsinmoderationasexcessiveconsumptioncouldcause
vitaminAtoxicity
avoidundercookedmeatduetoriskofToxoplasmaandListeriacontamination
heathotdogsandcoldcutsuntilsteamingpriortoconsumption
avoiddelicatessenfoods,includingptandmeatspreadsduetoriskofListeria
contamination
washcuttingboards,dishes,utensils,andhandsinhot,soapywaterafter
contactwithuncookedmeat
seafood
seafoodstoavoidinclude
shark,swordfish,mackerel,tilefish,andtunasteaksduetohighlevelsof
mercury(canleadtoneurologicabnormalitiesinpregnantwomenand
neonates)
smokedseafoodduetoriskofListeriacontaminationreportedincasereports
rawfishandshellfishduetoriskofexposuretoNorovirusreportedincase
reports
eatfarmedsalmoninmoderationasincreasedlevelsoforganicpollutantshave
beenfoundinfarmedsalmon
limitintakeofotherfish,includingcannedfish,to12oz/week
herbalteas
avoidteaswithchamomile,licorice,peppermint,orraspberryleafassometeas
havebeenassociatedwithadverseeffects,includingincreaseduterineblood
flow,uterinecontraction,andspontaneousabortion
teaswithginger,citruspeel,lemonbalm,androsehipsreportedtobesafewhen
usedinmoderation
preventionandmanagementlisteriosisinpregnantwomen
encouragewomentoavoidfoodsathighriskofcontaminationwithListeria,including
hotdogs,lunchmeats,andcoldcuts(maybeeatenifheatedtointernal
temperatureof74degreesC(165degreesF)orsteaminghot
refrigeratedpateandmeatspreads
refrigeratedsmokedseafoods
raw(unpasteurizedmilk)
unpasteurizedsoftcheeses,suchasfeta,quesoblanco,quesofresco,Brie,queso
panela,Camambert,andblueveinedcheeses
71/85
20/11/2015
DynaMed
unwashedrawproduce
managementofwomenwithsuspectedexposuretoListeriamonocytogenes
ifpatientisasymptomatic,notestingortreatmentneeded
ifpatientissymptomatic(flulikesymptomsincludemyalgia,abdominalorbackpain,
nausea,vomiting,ordiarrhea)
ifafebrile,considerobtainingbloodculturesandmanageexpectantly
iffebrile
performsimultaneoustestingwithbloodculturesandtreatmentwithIV
ampicillin(trimethoprimwithsulfamethoxazoleifpatientisallergictopenicillin)
obtainplacentalcultureifdelivered
ReferenceACOGcommitteeopiniononmanagementofpregnantwomenwith
presumptiveexposuretoListeriamonocytogenes(ObstetGynecol2014
Dec124(6):1241)
seealsoListeriosisinpregnancy
Vitamins,mineralsandothersupplements:
Prenatalormultivitamins:
noevidencethatuniversalsupplementationwithprenatalormultivitaminsinpregnancyis
beneficial(1)
prenatalvitaminsmaybeindicatedfor
womenwithmultiplegestations
womenwithtobaccoorchemicaluse
vegetarians
womenwithinadequatedietdespitecounseling
multivitaminnotrecommendedinpregnantwomenduetodifferingnutritional
requirementsinpregnancy
womenwhohavehadbariatricsurgeryorwhoarevegansmayrequiresupplementation
withiron,vitaminB12,folate,andcalcium(1)
Folatesupplementation:
folatesupplementationrecommendedpericonceptionallyandduringpregnancyfor
preventionofneuraltubedefects
AcademyofNutritionandDieteticsrecommendations
400mcg/dayfolicacidforallwomenofchildbearingpotentialbeginning1month
beforeconceptionbyconsumptionoffortifiedfoods,supplements,orboth,in
additiontoconsumingavarieddietcontainingdietaryfolate
600mcg/dayfolicacidforallpregnantwomen
dietaryfolateequivalentsadjustfordifferencesinbioavailabilityoffoodfolate
comparedwithsyntheticfolicacid
1mcgfolatefromsyntheticsourcesandfortifiedfoodsisequivalentto1.7mcg
dietaryfolateequivalents
4,000mcg/dayfolicacidbeforeandthroughoutthefirsttrimesterofpregnancyfor
72/85
20/11/2015
DynaMed
allwomenwithpreviousinfantwithaneuraltubedefect
naturalsourcesrichindietaryfolateinclude
legumes
greenleafyvegetables
liver
citrusfruitsandjuices
wholewheatbread
ReferenceJAcadNutrDiet2014Jul114(7):1099
considerfolate4,000mcgdailyinmotherstakingphenytoin,phenobarbital,or
primidone(anticonvulsantsarefolateantagonists)(JAmCollNutr2003Feb22(1):1)
seeNutritioninpregnancyforadditionalinformation
Calciumsupplementation:
considercalciumsupplementationforwomenwithlowdietarycalcium(<700mg/day),
butuniversalsupplementationnotrecommended(1,2)
recommendeddoseinpregnantwomenis1,2001,500mg/day
reportedtoreduceriskofpreeclampsiaby30%50%inwomenwithlowdietary
calcium
calciumsupplementation1g/dayduringpregnancyreducesriskof
preeclampsiaandcompositeoutcomeofmaternaldeathorseriousmorbidity
(level1[likelyreliable]evidence)
systematicreviewof13randomizedtrialscomparingcalciumsupplementation1
g/dayvs.placeboin15,730pregnantwomen
calciumsupplementation1g/dayassociatedwith
reducedpreeclampsiainanalysisof13trialswith15,730women
riskratio(RR)0.45(95%CI0.310.65)
NNT2548withpreeclampsiain6%ofplacebogroup
resultslimitedbysignificantheterogeneity
reducedmaternaldeathorseriousmorbidityinanalysisof4trialswith9,732
women
RR0.8(95%CI0.650.97)
NNT72834withmaternaldeathorseriousmorbidityin4%ofplacebogroup
almostallwomenwerelowriskandhadalowcalciumdiet
resultsalmostentirelybasedonWHOtrial
decreasedriskofchildhoodsystolicbloodpressure>95thpercentilein1trial
with514children
increasedriskofhemolysis,elevatedliverenzymes,lowplatelets(HELLP)
syndrome
RR2.67,95%CI1.056.82inanalysisof2trialswith12,901women
actualnumberofeventswaslow(16withcalciumvs.6placebo)
forpreeclampsia,greaterriskreductionsobservedinhighriskwomen,thosewith
73/85
20/11/2015
DynaMed
lowbaselinecalciumintake,andintrialswith<400women(smallertrialstendedto
enrollhighriskwomen)
nosignificantdifferenceinriskofstillbirthordeathbeforehospitaldischargein
analysisof11trialswith15,665infants
calcium1,500mg/daysupplementationmaynotreduceriskof
preeclampsiaormaternalmortality,butmayreduceseverityof
preeclampsia,riskofeclampsia,andneonataldeathinpregnantwomen
withlowdietarycalciumintake(level2[midlevel]evidence)
basedonlargestrandomizedtrialinaboveCochranereviewwithinadequate
statisticalpower
8,325healthynulliparouswomenincommunitieswithlowdietarycalciumintake
(<600mg/day)wererandomizedtocalciumcarbonate(500mgofcalcium)vs.
placebochewabletablets3timesdailyuntildelivery
meangestationatrandomizationwas15.1weeksforbothgroups
assignedtreatmentwasdiscontinuedifnephrolithiasisoccurredormagnesium
sulfateusedtotreatpreeclampsia
8,312women(99.8%)wereincludedinintentiontotreatanalysis
studywasunderpoweredtodetecta10%differenceinincidenceof
preeclampsia
nodifferencecomparingwomenwithcalciumsupplementationvs.placebofor
outcomesof
preeclampsia(4.1%vs.4.5%)
severepreeclampsia(0.8%vs.1.1%)
earlyonsetpreeclampsiaoreclampsia(<32weeksgestation)(0.46%vs.
0.53%)
calciumsupplementationassociatedwithreducedriskof
severegestationalhypertension(adjustedriskratio(RR)0.71,95%CI0.61
0.82)
eclampsia(adjustedRR0.68,95%CI0.480.97)
compositeofseverepreeclampticcomplications,definedassevere
preeclampsia,preeclampsiabefore32weeksgestation,eclampsia,placental
abruption,hemolysis,elevatedliverenzymes,lowplatelets(HELLP)syndrome,
orseveregestationalhypertension(adjustedRR0.76,95%CI0.660.89)
anymaternaladmissiontointensiveorspecialcareunit(adjustedRR0.85,
95%CI0.750.95)
comparingwomenwithcalciumsupplementationvs.placebo
maternaldeathin0.02%vs.0.14%(RR0.17,95%CI0.030.76)
neonataldeathin0.94%vs.1.3%(RR0.7,95%CI0.560.88)
ReferenceWHOtrial(AmJObstetGynecol2006Mar194(3):639)
calciumsupplementation<1g/dayduringpregnancymayreduceriskof
74/85
20/11/2015
DynaMed
preeclampsia(level3[lackingdirect]evidence)
basedonnonclinicaloutcomeinsystematicreviewwithincompleteassessmentof
trialquality
systematicreviewof9randomizedtrialsevaluatinglowdose(<1g/day)calcium
supplementationduringpregnancyforpreventionofpreeclampsiain2,234women
calciumaloneadministeredin4trials,calciumplusothersupplements(vitaminD,
linoleicacid,orantioxidants)administeredin5trials
allocationconcealmentwasonlytrialqualitycriterionassessed
lowdosecalciumassociatedwithdecreasedriskofpreeclampsiavs.placeboorno
calcium(relativerisk0.36(95%CI0.230.57)inanalysisof4trialswith980women
evaluatingcalciumsupplementationalone
ReferenceBJOG2014Jul121(8):951fulltext
calciumandlinoleicacidduringthirdtrimestermayreduceincidenceof
preeclampsiainhighriskpatients(level3[lackingdirect]evidence)
basedonrandomizedtrialwithnonclinicaloutcomes
1,676healthyprimigravidpatientsat2832weeksgestationscreenedforhighrisk
ofpreeclampsia(definedasbiopsychosocialprofilescoreof3ormore,positiveroll
overtest,andmeanarterialpressureatleast85mmHg)
89women(5.3%)methighriskcriteriaandwererandomizedtolinoleicacid450
mgpluscalcium600mgvs.placeboorallyoncedaily
9.3%treatmentvs.37.2%placebohadpreeclampsia(definedasbloodpressure>
140/90repeatedlyandproteinuria>0.3g/L)(p<0.001,NNT4)
nosignificantdifferencebetweengroupsforseverepreeclamptictoxemia(4.7%vs.
14%)
ReferenceObstetGynecol1998Apr91(4):585inAmFamPhysician1998
Jul58(1)252
DynaMedcommentary
useof<6%screenedpatientsandatypicalinclusioncriterialimits
generalizabilityofresults
thistrialexcludedfromCochranereviewbecauseofcotreatmentwithlinoleic
acid
calciumsupplementationduringpregnancydoesnotappeartoaffectblood
pressureinwomenwithlowcalciumintake(level3[lackingdirect]evidence)
basedonnonclinicaloutcomefromrandomizedtrialwithoutintentiontotreat
analysis
662pregnantwomenat20weeksgestationwithlowcalciumdietinGambiawere
randomizedtocalciumsupplementation1,500mg/dayvs.placebountildeliveryand
followedup1yearpostpartum
525motherinfantpairs(79%ofwomenrandomized)includedinanalysis
atbaselinemeanbloodpressure102/55mmHg
comparingcalciumvs.placeboat36weeksgestation
75/85
20/11/2015
DynaMed
meanincreaseinmaternalsystolicbloodpressure2.2vs.2.8mmHg(not
significant)
meanincreaseinmaternaldiastolicbloodpressure4vs.3.8mmHg(not
significant)
meanincreaseinmaternalweight4kg(8.8lbs)vs.4.3kg(9.5lbs)(not
significant)
nosignificantdifferencesininfantanthropometricmeasurementsatanytimepoint
evaluated
ReferenceAmJClinNutr2013Oct98(4):972fulltext
seeHypertensivedisordersofpregnancyforadditionalinformation
seealsoCalciumintakeandsupplementation
VitaminDsupplementation:
vitaminDsupplementationinpregnancytypicallyreservedforwomenwhoare
vegetariansorwholackvitaminDfortifiedmilkintheirdiet(1)
recommendeddoseisvitaminD400units(10mcg)daily,especiallyduringwinter
months
mayreduceriskofsymptomaticneonatalhypocalcemiaingroupsatincreasedrisk,
suchasSoutheastAsianwomenandwomenwholiveinnorthernclimates
WorldHealthOrganization(WHO)recommendationsforvitaminDsupplementationin
pregnancy
vitaminDsupplementationnotrecommendedtopreventpreeclampsiaorits
complicationsinpregnantwomen(strongrecommendation)
routinevitaminDsupplementationaspartofantenatalcarenotrecommendfor
improvingpregnancyoutcomes(conditionalrecommendation)
ReferenceWHOguidelineonvitaminDsupplementationinpregnantwomen(WHO
2012PDF)
AmericanCollegeofObstetriciansandGynecologists(ACOG)CommitteeOpinion495
onvitaminDdeficiencyscreeningandsupplementationduringpregnancy
insufficientevidencetosupportscreeningofallpregnantwomenforvitaminD
deficiency
evaluatingmaternalserumvitaminDlevelsofpregnantwomenatincreasedriskof
vitaminDdeficiencycanbeconsidered
vitaminD1,0002,000units/daythoughttobesafeforvitaminDdeficiencyin
pregnancy(higherdosesduringpregnancynotstudied)
ReferenceObstetGynecol2011Jul118(1):197,commentarycanbefoundin
ACOGNewsRelease2011Jun20
Omega3fattyacids:
omega3fattyacidsareessentialduringpregnancyandcanbeobtainedfromdietaryand
supplementalsources (1)
requirementsforomega3fattyacidsinpregnancynotyetestablished,butlikelyhigher
thanrequiredinnonpregnantwomen
76/85
20/11/2015
DynaMed
mostpregnantwomenmaynotgetenoughomega3fattyacidsduetorestricted
intakeofseafoodduringpregnancy
encouragepregnantwomentoconsumevarietyofsourcestoobtainadequateomega
3fattyacids,includingvegetableoils,2servingsoflowmercuryfish/week,and
supplements
Combinationformulations:
multiplemicronutrientpowdersforpointofusefortificationoffoodsduring
pregnancymighthavesimilarrateofmaternalanemiaatorneartermcompared
tomultiplemicronutrienttablets(level2[midlevel]evidence)
systematicreviewof2randomizedtrialsevaluatingmultiplemicronutrientpowders
containing3micronutrients(includingiron)forpointofusefortificationofsemisolid
foodsin1,172pregnantwomen
notrialscomparedmultiplemicronutrientpowderstoplacebo
comparingmultiplemicronutrientpowdersvs.multiplemicronutrienttabletin1trial
with470women
bothpreparationscontainedelementaliron15mg,folicacid400mcg,plus5other
micronutrients(zinc,iodine,vitaminE,vitaminC,andvitaminB12)andweregiven
oncedailyfor6monthsthenonceweeklyuntil3monthspostpartum
nosignificantdifferencebetweengroupsinmaternalanemiaatornearterm
maternaladherencenotreported
comparingmultiplemicronutrientpowdersvs.ironfolicacidtabletin1trialwith405
women
multiplemicronutrientpowderscontainedferrousfumarate60mg,folicacid400
mcg,vitaminC30mg,andzinc5mg
ironfolicacidtabletcontainedferrousfumarate60mgplusfolicacid400mcg
anyanemiaat32weeksgestationin48.8%vs.38.9%(p=0.047)
moderateanemiaat32weeksgestationin21.3%vs.12.1%(p=0.016)
maternaladherencein57.5%vs.75.8%(p=0.00013)
Exerciseinpregnancy:
exerciseduringpregnancy
generalrecommendations
30minutesofmoderateexercise/dayonmostoralldaysoftheweek
recommendedforpregnantwomenwithoutmedicalorobstetriccontraindications
encouragerecreationalandcompetitiveathleteswithuncomplicatedpregnanciesto
remainactiveduringpregnancywithmodificationstousualexerciseroutineas
medicallyindicated
advisephysicallyactivewomenwithhistoryofpretermlabororfetalgrowth
restrictiontoreduceactivityinsecondandthirdtrimesters
77/85
20/11/2015
DynaMed
womenwhoengageinvigorousexerciserequireclosemedicalsupervision
evaluatepreviouslyinactivewomenandthosewithmedicalorobstetric
complicationsbeforemakingrecommendationsforphysicalactivityinpregnancy
exerciseduringpregnancymaybeespeciallybeneficialinwomenwithgestational
diabetes
absolutecontraindicationstoaerobicexerciseinpregnancy
hemodynamicallysignificantheartdisease
restrictivelungdisease
incompetentcervix/cerclage
multiplegestationatriskforpretermlabor
persistentsecondorthirdtrimesterbleeding
placentapreviaat>26weeksgestation
prematurelaborincurrentpregnancy
rupturedmembranes
preeclampsia/pregnancyinducedhypertension
relativecontraindicationstoaerobicexerciseduringpregnancy
severeanemia
unevaluatedmaternalcardiacarrhythmia
chronicbronchitis
poorlycontrolledtype1diabetes
extrememorbidobesity
extremeunderweight(BMI<12kg/m2)
historyofextremelysedentarylifestyle
intrauterinegrowthrestrictionincurrentpregnancy
poorlycontrolledhypertension
orthopediclimitations
poorlycontrolledseizuredisorder
poorlycontrolledhyperthyroidism
heavysmoker
warningsignstostopexercisingwhilepregnant
vaginalbleeding
dyspneapriortoexertion
dizziness
headache
chestpain
muscleweakness
calfpainorswelling(ruleoutthrombophlebitis)
pretermlabor
decreasedfetalmovement
amnioticfluidleakage
ReferenceACOGcommitteeopinionno.267onexerciseduringpregnancyandthe
78/85
20/11/2015
DynaMed
postpartumperiod(ObstetGynecol2002Jan99(1):171),reaffirmed2009Jan
ACOGproposedrecommendationsforaddingincreasedexerciseintensityandstrength
trainingtoexerciseguidelinesinpregnancy
higherintensityexercisemaylimitweightgainmoreeffectivelythanlowintensity
exerciseinoverweightandobesepregnantwomen
safetyguidelinesformusclestrengtheningduringpregnancy
consider810musclestrengtheningexercisesperformedin12sessions/weekon
nonconsecutivedays
uselighterweightsandmorerepetitionstoavoidoverloadingjointsloosenedby
increasedlevelsofhormonerelaxininpregnancy
trytoavoidwalkinglungestoreduceriskforinjurytoconnectivetissueinpelvic
area
trynottoliftwhileflatonbackinsecondandthirdtrimestersduetopotentialto
compressinferiorvenacava
trytoavoidvalsalvamaneuverwhichmayincreasebloodpressureandintra
abdominalpressure,anddecreaseoxygenflowtofetus
listentoyourbodyandmodifyfrequencyandintensityofexercisesaccordingly
ReferenceObstetGynecol2011Jun117(6):1399
exerciseduringpregnancyassociatedwithimprovedmaternaloutcomesand
doesnotappeartonegativelyaffectfetalwellbeing(level2[midlevel]
evidence)
basedon1systematicreviewlimitedbyclinicalheterogeneityand1nonrandomized
trial
systematicreviewof19randomizedtrialsevaluatingphysicalexerciseduring
pregnancyinabout4,531healthypregnantwomen
nometaanalysisperformedduetoclinicalheterogeneityinexercisesregimensand
outcomemeasures
physicalexerciseduringpregnancyassociatedwith
highercardiorespiratoryfitnessin1trialwith64women
reducedlikelihoodofurinaryincontinencein3trialswith691women
reducedincidenceoflowbackpainin2trialswith905women
reducedsymptomsofdepressionin2trials799women
gestationalweightcontrolin4trialswith696women
reducednumberofwomenwithgestationaldiabeteswhorequiredinsulinin3
trialswith1,002women
physicalexercisenotassociatedwithreducedbirthweightorpretermbirthweightin
2trialswith172women
ReferenceCurrOpinObstetGynecol2012Dec24(6):387
nonrandomizedtrialof45healthypregnantwomenbetween28weeksand32weeks
6daysgestation(15nonexercisers,15regularlyactive,15highlyactive)whowere
exercisedtovolitionalfatigue,thentargetheartratescalculatedfortwosubsequent
79/85
20/11/2015
DynaMed
30minutetreadmillsessionsandmeasurementsoffetalwellbeingevaluated
inactivewomenperformed2moderatetreadmilltests(40%59%heartrate
reserve)
activewomenperformed1moderatetreadmilltestand1vigoroustreadmilltest
(60%84%heartratereserve)
withmoderateexercise,nosignificantdifferencesinumbilicalarteryDopplerindices
preexerciseandpostexerciseamonggroups
withvigorousexercise,Dopplersweresimilarinregularlyandhighlyactivewomen
withsignificantdecreasespostexercise(p<0.05)
allpostexercisefetalheartratetracingsmetcriteriaforreactivitywithin20minutes
afteralltests
biophysicalprofileswerereassuring
nosignificantdifferencesindeliveryvariablesamonggroups
ReferenceObstetGynecol2012Mar119(3):603fulltext,commentarycanbe
foundinJMidwiferyWomensHealth2012JulAug57(4):418andinSportverletz
Sportschaden2012Jun26(2):61
supervisedprenatalexerciseassociatedwithreducedriskofhavinglargefor
gestationalagenewborn(level2[midlevel]evidence)
basedonsystematicreviewofmostlylowtomoderatequalitytrials
systematicreviewof28randomizedtrialsevaluatingtheeffectsofstructuredprenatal
exercise(comparedwithstandardprenatalcarealone)onnewbornbirthweight,
macrosomia,andgrowthrestrictionin5,322pregnancies
supervisedexercisedefinedas1exercisesessionperformedwithstudypersonnel
every2weeksthroughoutstudyduration
supervisedprenatalexerciseassociatedwithreducedriskofhavingalargenewborn
(birthweight4,000gor>90thpercentileforageandsex)(oddsratio0.69,95%CI
0.550.86)
noassociationnotedbetweensupervisedprenatalexerciseandriskofhavingsmall
forgestationalagenewborn,ordeliveringprematurely
behaviorchangetechniquesincorporatingphysicalactivitymayhelpreduce
declineinphysicalactivitythroughoutpregnancy(level2[midlevel]evidence)
basedonsystematicreviewoftrialswithmethodologiclimitations
systematicreviewof14randomizedstudiesevaluatingbehaviorchangeinterventions
(counseling,structuredexerciseand/oreducation)forreducingdeclineinphysical
activityduringpregnancyin2,553pregnantwomen
alltrialshad1oftheselimitations
unclearrandomizationsequencegeneration
baselinedifferencesbetweengroups
80/85
20/11/2015
DynaMed
nometaanalysisperformedduetoheterogeneityofphysicalactivitymeasuresand
controls
12studiescomparedinterventionstostandardcarebutdidnotdefinestandardcare
1studycomparedinterventionstostretching
1studycomparedinterventionstohealthandwellnessgroup
comparedtocontrolsin10trialsprovidingphysicalactivitydata,behaviorchange
interventionswithphysicalactivityassociatedwith
significantlyincreasedphysicalactivityin8trials
significantlylessdecreaseinphysicalactivitythroughoutpregnancyin2trials
ReferencePLoSOne20138(6):e66385fulltext
Workduringpregnancy:
fulltimeorparttimeworknotassociatedwithpretermbirthorlowbirthweight
basedonretrospectivecohortstudy
1,573womenwhodeliveredsingletonbabyin2005withdatafromtheListeningto
MothersIIsurveywereevaluated
comparedtowomenwhowerenotemployed,neitherfulltimenorparttime
employmentwereassociatedwithpretermbirthorlowbirthweight
ReferenceWomensHealthIssues2013MarApr23(2):e77fulltext
physicallydemandingworknotassociatedwithincreasedriskofpretermor
smallforgestationalagebirth
cohortstudywith
analysisof1,908womenforoutcomeofpretermdelivery,ofwhom234(12.3%)
hadpretermdelivery
analysisof1,712womenforoutcomeofpretermdelivery,ofwhom142(8.3%)had
pretermdelivery
nosignificantassociationswithliftingrepeatedly
nosignificantassociationswithstandingatleast30hours/week
nightshiftworkassociatedwith1.5timesriskforpretermdeliverywithborderline
statisticalsignificance
workingatleast46hours/weekassociatedwith40%relativeriskreductioninpreterm
delivery
ReferenceObstetGynecol2005Dec106(6):1279,commentarycanbefoundin
EvidenceBasedMedicine2006SepOct11(5):156
workoutsideofhomeassociatedwithslightincreaseinbloodpressure,butlittle
clinicalsignificanceinnormotensivewomen
100normotensivewomenat30weeksgestationhad24hourambulatoryblood
pressuremonitoringonworkandnonworkdays,
meanincreaseinbloodpressureatwork2.6mmHgsystolic(p<0.001)and2.8mm
Hgdiastolic(p<0.001)
81/85
20/11/2015
DynaMed
morethan10%womenhadmeanincreaseinbloodpressure>10mmHgonwork
days,whichwasassociatedwithhigherbloodpressureandgreaterperceivedjob
stress
meanincreaseinbloodpressure6.47.4mmHgamong12womenwhodeveloped
hypertension
ReferenceObstetGynecol2001Mar97(3):361
relatedguidelines
UniversityofTexasatAustinSchoolofNursingFamilyNursePractitionerProgram
occupationalguidanceforphysicalandshiftworkofpregnantwomeninUnitedStates
canbefoundatNationalGuidelineClearinghouse2014Sep1:48219
AmericanCollegeofOccupationalEnvironmentalMedicine(ACOEM)guidanceon
reproductiveanddevelopmentalhazardmanagementcanbefoundinJOccupEnviron
Med2011Aug53(8):941
CincinnatiChildren'sHospitalMedicalCenter(CCMC)Bestevidencestatement(BESt)
onexposureofpregnanthealthcareworkerstoradioisotopeNeuroliteteratogenicrisks
canbefoundatNationalGuidelineClearinghouse2011Oct3:33280
SocietyofObstetriciansandGynaecologistsofCanada(SOGC)guidelineonmaternity
leaveinnormalpregnancycanbefoundinJObstetGynaecolCan2011
Aug33(8):864PDForatNationalGuidelineClearinghouse2011Dec12:34405
Dentalcare:
AmericanCollegeofObstetriciansandGynecologists(ACOG)recommendationsfororal
healthcareduringpregnancy
discussoralhealthwithallpatients
advisewomenthatoralhealthcareimprovesgeneralhealthandmayreduce
transmissionofpotentiallycariesproducingoralbacteriafrommothertoinfant
performoralhealthcareassessmentatfirstvisit
encourageroutineoralhealthmaintenance,includinglimitingsugaryfoodsanddrinks,
brushingtwiceadaywithfluoridatedtoothpaste,flossingoncedaily,anddentalvisits
twice/year
advisewomenthatprevention,diagnosis,andtreatmentoforalconditions,including
dentalxrays(withshieldingofabdomenandthyroid)andlocalanesthesia(lidocaine
withorwithoutepinephrine)aresafeduringpregnancy
advisewomenthatconditionsrequiringimmediatetreatment(suchasextractions,root
canals,andrestorationofuntreatedcaries)maybemanagedatanytimeduring
pregnancy,anddelayingtreatmentcouldleadtomorecomplexproblems
advisepatientsthatuseofantacidsorrinsingwithbakingsodasolution(1teaspoon
bakingsodadissolvedin1cupofwater)mayhelpneutralizeacidassociatedwith
vomitingsecondarytomorningsicknessorhyperemesisgravidarum
gastricrefluxduringlatepregnancy
ReferenceACOGcommitteeopinionno.569onoralhealthcareduringpregnancyand
throughthelifespan(ObstetGynecol2013Aug122(2Pt1):417)
82/85
20/11/2015
DynaMed
treatmentofperiodontaldiseaseduringpregnancymayreduceriskforpreterm
birthandlowbirthweightbutdoesnotappeartoaffectratesofmiscarriageor
stillbirth(level2[midlevel]evidence)
basedonsystematicreviewoftrialswithmethodologiclimitations
systematicreviewof10randomizedtrialscomparingperiodontaltreatmentvs.no
treatmentin5,645pregnantwomenwithperiodontaldisease(periodontitisor
gingivitis)
alltrialshad1ofthesemethodologiclimitations
unclearallocationconcealment
unclearrandomizationsequencegeneration
baselinedifferencesbetweengroups
lowpatientadherence
periodontaltreatmentincludedscalingand/orrootplanningand/ororalhygiene
education
comparedtonotreatment,treatmentofperiodontaldiseaseassociatedwith
decreasedriskfor
pretermbirth(oddsratio[OR]0.65,95%CI0.450.93)inanalysisofalltrials
lowbirthweightneonates(OR0.53,95%CI0.310.92)inanalysisof7trialswith
4,105women
nosignificantdifferencesbetweengroupsinratesofmiscarriage/stillbirth(OR0.71,
95%CI0.431.16)inanalysisof8trialswith5,070women
ReferenceIntJEvidBasedHealthc2011Jun9(2):122,commentarycanbefoundin
IntJEvidBasedHealthc2011Dec9(4):450
nonsurgicaltreatmentofmaternalperiodontaldiseasenotassociatedwithpoor
cognitiveoutcomesinchildrenat2years(level2[midlevel]evidence)
basedonsecondaryanalysisofrandomizedtrial
411childrenaged2428months,whosemothershadbeenrandomizedtononsurgical
treatmentofperiodontaldiseasebefore21weeksgestationvs.afterdeliverywere
evaluatedbychildpsychologists,occupationaltherapists,speechpathologists,and
physicaltherapists
nosignificantdifferenceinmeancognitive,motor,orlanguagescores
ReferencePediatrics2011May127(5):e1212fulltext
maternalexposuretoxylitolgumassociatedwithdecreasedlikelihoodof
mutansstreptococciinchildrenaged9,12,and24months(level3[lacking
direct]evidence)
basedonrandomizedtrialwithdifferentialdropoutandwithoutclinicaloutcomes
107pregnantwomenwithhighsalivarymutansstreptococci(MS)randomizedtoxylitol
gum(chewinginitiatedatsixthmonthofpregnancyandcontinuedfor13months)vs.
nogum
salivasamplestakenfromchildrenduringsame2hourperiodat6,9,12,18and24
83/85
20/11/2015
DynaMed
monthsofage
17%dropoutrateinxylitolgroupand39%incontrolgroup
xylitolgrouphadreducedlikelihoodofMScolonizationininfantsaged
9months(p=0.014)
12months(p<0.001)
24months(p<0.007)
ReferenceJDentRes2010Jan89(1):56
EBSCOhostFullText,commentarycan
befoundinJEvidBasedDentPract2011Mar11(1):62
preventiveoralhealthservicesduringpregnancynotcurrentlypartofstandard
careinAustraliadespiteevidenceofbenefit
basedonsystematicreview
nopreventivestrategiesexistinAustraliafocusingonmaintenanceorimprovementof
oralhealthduringpregnancyuseofmidwivesmayfacilitateimprovements
ReferenceJClinNurs2010Dec19(2324):3324
reviewoforalhealthduringpregnancycanbefoundinAmFamPhysician2008Apr
1577(8):1139fulltext
reviewofmaternaloralhealthinpregnancycanbefoundinObstetGynecol2008
Apr111(4):976
toolboxpromotingoralhealthofinfants,children,andadolescentsfromNationalMaternal
andChildOralHealthResourceCenterandBrightFutures
Otherinterventions:
prophylacticabdominaldecompressiondoesnotappeartoimprovepregnancy
outcomesinhealthywomen(level2[midlevel]evidence)
systematicreviewof2randomizedtrialscomparingprophylacticabdominal
decompression(negativepressuretospacearoundabdomen)todummy
decompressionornotreatmentinhealthypregnantwomen
1trialhadhighdropoutrateand1trialusedaninvalidplacebo(abdominal
decompressionat20mmHg)
nosignificantdifferencesin
admissionsforpreeclampsiain1trialwith411women
perinatalmortalityinanalysisof2trialswith709infants
lowbirthweightin1trialwith253infants
Apgarscore<4at1minutein1trialwith242infants
QualityImprovement
GuidelinesandResources
PatientInformation
ICD9/10CodesandCPTCodes
References
84/85
20/11/2015
DynaMed
YouareviewingaDynaMedsummary.UseofDynaMedindicatesacceptanceofDynaMed
TermsofUse.LimitationsofDynaMedarecontainedintheDynaMedTermsofUse.
PleasegiveusyourfeedbackbyemailingDynaMedat:DynaMedEditor@ebscohost.com
TopofPage
EBSCOSupportSitePrivacyPolicyTermsofUseCopyright
2015EBSCOIndustries,Inc.Allrightsreserved.
85/85

Routine of Prenatal Care

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Routine of Prenatal Care

Caricato da

Copyright:

Formati disponibili

20/11/2015

Potrebbero piacerti anche