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The Right Stuff: Applying Evidence to Routine Prenatal Care

William Ehman MDOctober 27, 2011

Learning Objectives

• Current evidence based recommendations for routine prenatal care

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

providers)▫ Pregnancy Passport (women)

• Practical advice on some common issues

• Immerging antenatal assessment options

Maternity Care Pathway2010

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

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

• High quality• Accessible• ‘Woman centered’

Maternity Care Enhancement Project 2004

The Care

Who Provides Care: Canada?

Prenatal Care

OB FP MW RN

Canada 58% 34% 6% 1%

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

Birth

OB FP MW RN

Canada 70% 15% 4% 5%

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

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

Developmental Origins of Health & Disease

Adverse Pre-pregnancy

health

Adverse Intrauterine

EnvironmentAdult Disease

CHD, Stroke,Hypertension

Insulin resistanceDyslipidemia

Anxiety/depression

Adult DiseaseCHD, Stroke,Hypertension

Insulin resistanceDyslipidemia

Anxiety/depression

Adverse Postnatal

Environment

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

%%

BirthweightBirthweight

Prevalence of future diabetesPrevalence of

future diabetes

PSBC Guideline Maternity Care Pathway 2010

Where the Pathway starts:

Why?• 50% unplanned• Early organogenesis

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

PSBC Guideline Maternity Care Pathway 2010

(and Prenatal)

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

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

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

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

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

• Calcium – 1000 mg/d

• Iron: 15 to 20 mg supplement3

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

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

3Health Canada, 2010

Preconception/Prenatal - Supplements

• Wash▫ fruits & vegetables

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

• Avoid▫ Direct contact with soil, animal feces

Food Safety:Toxoplasmosis/Listeriosis/Salmonella:

• Good: omega-3FAs: fetal brain/eye

• Bad: Mercury

Fish (the good & the bad)

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

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

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

Health Canada, FDA, EPA

“HERBS TO AVOID OR USE WITH CAUTION DURING PREGNANCY”

• Angelica - stimulates suppressed menstruation

• Black Cohosh - uterine stimulant - mostly used during labor

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

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

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

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

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

the developing fetus, also should not be used if nursing

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

developing fetus

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

• Motherwort - stimulates suppressed menstruation

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

doses• Pennyroyal Leaf - stimulates uterine

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

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

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

sugar during pregnancy and nursing• Yarrow - uterine stimulant

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

• maximum daily caffeine intake = 2001-300 mg2

CaffeineFoods and Beverages Caffeine

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

13776

Tea (8 oz.)BrewedInstant

4830

Cola & caffeinated drinks (12 oz) 37

Hot cocoa (12 oz) 10

Chocolate Milk (8 oz) 8

1 Food Standard Agency , UK2 NICE 2008

Underweight (BMI <18.5)• 6%1

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

OW/Obese (BMI>25&30)• 35% (21 + 14%)1

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

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

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

1. IGT2. lipids -prostocylin &

peroxidase→vasoconstriction & platelet aggregation

3. O2 with sleep apnea4. awareness of FM

Weight Before Pregnancy

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

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

Genetic screening & family history

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

Substance:• Screen• Council, refer• Harm reduction

Medications:• Prescription• OTCs

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

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

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

Tobacco• Screen all1

Alcohol “insufficient evidence to define

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

1BCPHP Guideline 092SOGC ‘10

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

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

herpes

syphilis

toxoplasmosis

rubellaCMV

Vaccination• Preconception:▫ Update▫ Seasonal influenza

• Inactivated vaccines & toxoids - are safe

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

Inactivated & Toxoids

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

Live & live-attenuated

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

In Due Time: Why Maternal Age Matters

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

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

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

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

&pf=PFC1656

Maternal Age

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

Fertility and Sterility 1957;8:89-97.

7% 11%

33%

87%

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

100%

30 35 40 45

Infertility Rate

• Risk IUFD:

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

Age (years)

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

30 - 34 1.24

35 - 39 1.45

40 – 44 3.04

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

PSBC Guideline Maternity Care Pathway 2010

(≥ 5 in UpToDate)

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

She is now pregnant!

PSBC Guideline Maternity Care Pathway 2010

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

IPS Integrated Prenatal ScreenSIPS + NT

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

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

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

Amniocentesis ≥15 wks

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

*

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

Abnormal Markers May Predict Complications

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

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

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

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

What to do?• Consultation to determine surveillance & Rx

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

Ut. A Doppler waveforms:

Normal

Abnormal

The Model of Care

16w

41w40w39w38w37w

36w34w32w30w

28w24w

Memorandum on Antenatal Clinics UK Min. of Health, 1929

Traditional

A New Model of Care?

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

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

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

Specialist care 12-34w

20w

37w

41w

From Nicolaides K, Prenat Diagn 2011

(0-14wks)

PSBC Guideline Maternity Care Pathway 2010

PSBC Guideline Maternity Care Pathway 2010

(0-14wks)

Work – risk factors1

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

Hot Tubs/Baths• water temp < 39 2

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

Soy(chloasma)

INSTITUTE FOR CLINICALSYSTEMS IMPROVEMENT

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

Exercise• “All without contraindications encouraged to participate in

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

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

• “at least 30 min. most days”2

• Core, talk test, temp. not > 38°

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

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

Screening/Diagnostic Tests (0-14wks)

Test LORBlood Group, Rh, Antibodies C Hemolytic disease

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

Rubella Ab Titre B PP vaccination if not immune

STS A

HBsAg A Guide Mat. & NB care

TSH B Offer all

Chlamydia screen B Offer to all

Gonorrhoea A Offer to all

Midstream urine C/S AC

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

B Fair evidence for

C Conflicting

D Fair evidence against

I Insufficient

PSBC Guideline Maternity Care Pathway 2010

Screening/Diagnostic Tests (0-14wks)

Test L.O.R.

Hep C testing A Recommend with risk factors

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

Pap test B If indicated

B19, Mumps, Toxoplasmosis, CMV, etc

I No routine testing

B If women exposed/symptoms

TWEAK B Screen alcohol use, most sensitive in 1st

15 wks

A Good evidence for

B Fair evidence for

C Conflicting

D Fair evidence against

I InsufficientPSBC Guideline Maternity

Care Pathway 2010

PSBC Guideline Maternity Care Pathway 2010

Procedure L.O.R.

BP C

Fetal Movement BAB

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

FHR C

Symphysis Fundal Ht B Plotting on graph will asses growth

Urine dip for protein BCA

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

Weight measurement IB

To monitor esp. Under/over weightTo assist obese women

Routine Prenatal Care at each Appointment

A Good evidence for

B Fair evidence for

C Conflicting

D Fair evidence against

I Insufficient

PSBC Guideline Maternity Care Pathway 2010

& CBC

PSBC Guideline Maternity Care Pathway 2010

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

PSBC Guideline Maternity Care Pathway 2010

PSBC Guideline Maternity Care Pathway 2010

PSBC Guideline Maternity Care Pathway 2010

The Passport

PSBC Guideline Maternity Care Pathway 2010

PregnancyPassport1. Things to

discuss & expected care

PregnancyPassport2. Goals &

decision points

PregnancyPassport3. Resources

Thank you

William Ehman MD