classification: internal use only · and positive confirmatory mha-tp, fta-abs, or tp-pa. b....

Classification: Internal Use Only

Classification: Internal Use Only 1

Protocol Title: Urgent, Intermediate, & High-Risk OB Referral Protocol

Effective Date: 06/01/16 Version: 1.0

Approval By: CCC Clinical Delivery Steering; CCC Women’s Health Workgroup

Planned Review Date: 06/01/2017

1 Purpose & Objective This protocol provides referral recommendations for the care of all pregnant patients.

2 Scope of Protocol

2.1 Target Population

This protocol was derived from clinical guidelines for pregnant individuals in the CCC population.

2.2 Target Users

This protocol is developed for use in primary care settings.

2.3 Excluded Topics

This protocol does not address the clinical management of patients with complications of pregnancy.

2.4 Related Guidelines



3 Protocol Development & Approval Process

This protocol originated in a subcommittee of the CCC Women’s Health Workgroup. The work of the

subcommittee included clinical experts and operations staff from Dell Medical School at UT Austin, Seton

Healthcare Family, CommUnityCare, Lone Star Circle of Care, El Buen Samaritano, People’s Community

Clinic, and Community Care Collaborative. The depiction above describes the approval and subsequent

review process for this protocol.

At minimum, will be

reviewed annually

At minimum, will be

reviewed annually

Tracked and reported on a

regular, consistent basis



Group Name Approval Date

CCC Women’s Health Workgroup Subcommittee 03/15/2016

CCC Women’s Health Workgroup 03/22/16

CCC Clinical Protocols Workgroup n/a

CCC Clinical Delivery System Steering Group 04/27/16

CCC Advisory Committee

CCC Board of Directors

4 Emergency Referral

4.1 Timing and Process

Patients meeting criteria for emergency referral at or above 20 weeks gestation should be referred to the

OB Triage Area at SMCA. If the patient is less than 20 weeks, refer to SMCA Emergency. Specific conditions

identified below (for example, myocardial infarction) should be referred directly to the emergency room at

SMCA.

Physicians, CNMs, APRNs and RNs providing care in the outlying clinics have the option to consult with the

hospital-based physicians and develop an alternate plan of care based on individual patient needs. (Please

note it may deviate from CCC’s established protocol.)

SMCA OB Faculty: (512) 897-3733

SMCA L&D: (512) 324-1027

SDMC L&D: (512) 544-4222

4.2 Criteria

A. Gestational Hypertension/Preeclampsia 1. Gestational hypertension: Refer for BP ≥ 140/90 x 2 seated at same visit 20 minutes apart

2. Preeclampsia: Refer for BP ≥ 140/90 and one

or more of the following: a. Proteinuria ≥ 2+ b. Severe persistent headache, altered

mental status or new onset seizures c. Visual disturbances d. Epigastric/right upper quadrant pain,

nausea/vomiting



e. Shortness of breath

B. Hypertension – Chronic Chronic hypertension with superimposed preeclampsia: refer for above symptoms

and/or BP ≥ 160/100 C. Thromboembolic Disorders Unexplained shortness of breath or unexplained

swelling of a lower extremity D. Genito-urinary Disorders Evidence of vaginal bleeding in the first

trimester due to suspected ectopic pregnancy, hydatidiform mole, missed abortion, or threatened abortion; vaginal bleeding in the second trimester due to suspected abruption or placenta previa. Gross hematuria, renal colic, adnexal torsion, or suspected extra-uterine pregnancy

E. Gastrointestinal Disorders Hyperemesis gravidarum with ketonuria, biliary colic, hematemesis, melena

F. Heart Disease/Lung Disease Decompensated cardiovascular, or pulmonary

disease (e.g., heart failure, arrhythmia, myocardial infarction, asthmatic crisis, pulmonary edema, hemoptysis)

G. Endocrinopathies Diabetic ketoacidosis, symptomatic

hypoglycemia, thyroid storm, adrenal crisis H. Ruptured Membranes Rupture of membranes confirmed by available

testing I. Infectious Diseases Evidence of suspected or active tuberculosis,

epiglottitis, pneumonia, endocarditis, chorioamnionitis, pyelonephritis, severe gastroenteritis, cholecystitis, hepatitis, pancreatitis, appendicitis, abscess, meningoencephalitis, or sepsis

Suspected maternal infection with concern for

fetal compromise: toxoplasmosis, rubella, cytomegalovirus, parvovirus (Fifth’s disease), or

Varicella.



Suspected influenza with oxygen saturation less than 100% on room air.

J. Abnormal Fetal Heart Tones 1. Sustained (over 20 minutes), or recurrent

fetal tachycardia > 160 bpm or bradycardia < 110 bpm 2. Absence of previously noted fetal heart tones, or after 20 weeks gestation (check with Doppler or ultrasound)

K. Decreased Fetal Movements Decreased perceived fetal movements in the

third trimester

L. Contractions Preterm: uterine contractions occurring every 15 minutes at < 37 completed weeks of gestation

Term: uterine contractions occurring every

5 – 10 minutes accompanied by bloody show or documented progressive cervical change in dilation or effacement

M. Abnormal Fetal Ultrasound Fetal hydrops, oligohydramnios (< 5 cm

amniotic fluid index), abnormal Doppler velocimetry (indicating fetal anemia, severe placental insufficiency, or fetal cardiac decompensation), oligo-polyhydramnios sequence in multiple gestation

N. Trauma Recent (esp. abdominal, cranio-spinal) trauma

within the previous 24 hours O. Neurologic or Psychiatric Disorders Stroke, altered mental status, acute psychosis,

status epilepticus, or new onset seizures

5 Urgent Referral


Patients meeting these criteria should be referred to intermediate or high risk clinic site for evaluation and

treatment same day or following day.



5.2 Criteria for referral to Intermediate Risk Care Clinic

A. First Episode Genital Herpes A. Severe symptoms such as urinary retention necessitating admission

B. Post-dates Pregnancy B. Postdates, EGA > 40 weeks, by best clinical estimate

C. Urinary Tract Infections C. Refer if no response to appropriate treatment. Include data about culture and sensitivity of the organism. Also refer for > 2 episodes in current pregnancy despite appropriate treatment.

D. Elevated Diabetes Screen D. Blood glucose ≥200 mg/dl. (1-hour post 50 gm glucola challenge) E. Abnormal Fetal Lie E. Suspicion of transverse or oblique fetal lie or suspected

breech presentation after 36 weeks gestation

5.3 Criteria for referral to High Risk Care Clinic

A. Positive Antibody Screen A. Rh(D) negative gravida with positive antibody screen (exclude Rhesus immune globulin administration within the past 12 weeks), or previous gestation affected by Rh alloimmunization. If fetal hydrops is present, refer emergently. Positive screen for antibody known to cause fetal anemia especially anti-Kell and anti-c. No need for referral for anti-I, anti-P, or anti–Lewis. If antibody identification is not available at the clinic, refer for antibody identification and management. If fetal hydrops is present, refer emergently.

B. Chronic Hypertension B. BP ≥ 150/95 in calm sitting position on ≥ 2 readings at the same visit, despite appropriate antihypertensive therapy. If ACE inhibitors were taken during pregnancy, discontinue immediately and refer for initiation of alternative anti-hypertensive therapy.

6 Referral Following Initial History and Physical

6.1 Timing and Process History of chronic cardiovascular, pulmonary, renal, gastrointestinal, endocrine, autoimmune, neurologic, psychiatric, or infectious disease or drug abuse, refer within 1-4 weeks if patient is on medication, the



condition is under control and the patient is asymptomatic. Patients referred to the High Risk Clinic may follow in the Intermediate Risk Clinic after consult and recommendations of MFM. If patient is symptomatic make an emergency or urgent referral.

6.2 Criteria Based on Obstetric and Gynecologic History for referral to Intermediate Risk

Clinic

A. H/O Psychiatric Disorder, Drug or Alcohol Abuse or Domestic Violence

B. Evidence of HIV infection

A.

B.

Refer to appropriate psychiatric, drug counseling, or social worker services respectively. (May be urgent, as deemed necessary)

6.3 Confirmed by Fourth generation HIV Antigen/Antibody test or Western blot. Refer urgently if near term.

6.4 Criteria Based on Obstetric and Gynecologic History for referral to High Risk Clinic

A. H/O Recurrent Pregnancy Loss A. H/O ≥ 3 first trimester spontaneous abortions or ≥

2 second trimester spontaneous abortions

B. Previous Perinatal Death

B. Previous fetal death, stillborn, or neonatal death,

C. H/O Congenital Defect C. Previous major congenital defect, or heritable genetic disorder (Refer to Genetic Counseling Services & Ultrasound.)

D. Previous Termination for Maternal Medical Disease

D. Medically indicated termination of a previous pregnancy. Refer urgently if medical condition persists.



E. Uterine Abnormality

F. Cervical Abnormality

E. F.

Uterine abnormality (H/O Mullerian anomaly fibroids) History of incompetent cervix, cone biopsy, LEEP or cerclage)

G. Previous Preterm Birth, or Fetal Growth Restriction

G. If delivery was <36 weeks gestation or birth weight was <2,500g

H. H/O Seizure Disorder H. Refer for high risk (comprehensive ultrasound for NTD)

6.3 Criteria Found Through Medical Examination for referral to Intermediate Risk Clinic

A. Mode of Delivery

B. Uterine Size > Dates

A. Tumor, uterine anomaly or obstruction of the birth canal depending on gestational age

B. Fundal height noted to be 3 cm greater than the weeks of gestation after 24 weeks (suspected polyhydramnios, multiple gestation or fetal macrosomia)

C. Uterine Size < Dates C. Fundal height noted to be 3 cm less than the weeks of gestation after 24 weeks (suspected intrauterine growth restriction or oligohydramnios).

6.4 Criteria Found Through Medical Examination for referral to High Risk Clinic A. Multiple Gestation A. All multiple gestations should be referred for evaluation

6.5 Criteria Found Through Laboratory Results for referral to Intermediate Risk Clinic

A. Anemia A. 1. Severe anemia with Hgb <9 gm/dl or Hct <27%, IF unresponsive to oral iron/ascorbate therapy after 6 weeks.

2. Abnormal hemoglobin electrophoresis.



B. Abnormal 3° GTT

B. Abnormal 2o GTT

C. HIV infection

B. 3° GTT with 2 or more abnormal values (refer within one week of results):

> 95 mg/dl Fasting

> 180 mg/dl 1 hr

> 155 mg/dl 2 hr

> 140 mg/dl 3 hr

If resources are available, home glucose monitoring can be initiated in the outlying clinics.

B. 2o GTT with at least one abnormal value

(refer within one week of results):

> 92 mg/dl Fasting

> 180 mg/dl 1 hr

> 153 mg/dl 2 hr

If resources are available, home glucose monitoring can be initiated in the outlying clinics.

6.5 C. Confirmed by Fourth generation HIV Antigen/Antibody test or Western blot. Refer urgently if near term.

6.6 Criteria Found Through Laboratory Results for referral to High Risk Clinic

A. Syphilis A. Diagnosis requires both positive RPR or VDRL and positive confirmatory MHA-TP, FTA-ABS, or TP-PA.

B. Thrombocytopenia B. Thrombocytopenia < 90K/mm3 (repeat at least once to rule out lab error; consider sending repeat assay in heparinized tube (green top tube) if platelet clumping reported in initial sample.



7 Genetics Referral to Seton Genetics Clinic


Referral sent for genetic counseling and education as early as possible when indicated.

Risk classification and education ONLY will be done by the genetic counseling staff after 23 weeks gestation for the criteria as outlined below.

7.2 Criteria

A. Maternal Age A. Maternal age > 35 years old at delivery.

B. Abnormal Serum Screening/ Ultrasound Screening C. Family History

B. Abnormal findings on serum screen and/or ultrasound screening DO NOT REFER TO HIGH RISK CLINIC BEFORE GENETICS APPOINTMENT. C 1. Chromosomal Anomalies: a. Previous child, parent or sibling with a genetic anomaly (e.g., Down syndrome, Hemoglobinopathies, Thalassemia, Hemophilia, Duchenne’s Muscular Dystrophy, Marfan Syndrome, Ehlers-Danlos Syndrome, Congenital Adrenal Hyperplasia or any other inherited genetic disease). b. Either parent a known carrier of any chromosome anomaly or inherited genetic disease (as examples above).

2. Strong family history of mental retardation in a first degree relative (i.e., sibling, parent, previous child) or multiple family members.

3. Positive screening test for cystic fibrosis (CF), Spinal Muscular Atrophy or Tay Sacs

D. High Risk Groups D. Always refer couples of Jewish ancestry with positive carrier screens for Tay Sacs, Canavans and/or CF

Couples of Mediterranean, Southeast Asian: refer if maternal MCV < 80L.

African-American couples: refer if maternal hemoglobin electrophoresis reveals any hemoglobin S or C.



8 Referral Guidelines for Prenatal Ultrasound Examination All Patients:

An obstetrical ultrasound examination may be requested to coincide with the first prenatal visit. The purpose of this ultrasound is to validate patient’s menstrual dates.

An ultrasound should be scheduled for all patients between 18 and 20 weeks estimated gestational age at the Seton Antenatal Testing Unit. This ultrasound may serve as the dating ultrasound in the absence of a first trimester scan.

Seton Antenatal Testing Unit (512) 324-7256

9 Antenatal Testing

Listed below are current indications for antenatal testing. We anticipate that the majority of patients

who require antenatal testing will be receiving their care in the intermediate or high-risk clinics at the

pavilions. Decreased fetal movement in the third trimester should be evaluated in the respective

Obstetric triage unit.

Indications for antepartum testing include

1. A2 DM (includes patients on glyburide) 2. Pregestational DM (Type I and Type II) 3. Fetal growth restriction (estimated fetal weight less than the 10th percentile by recent ultrasound) 4. Hypertensive disorders, including gestational hypertension 5. Post term pregnancy (≥41 weeks’ gestation)

E. Previous Children

E. History of Congenital Adrenal Hyperplasia, neural tube defect (hydrocephalus, anencephaly, or spina bifida), cleft palate or limb anomalies, previous heart defect or fetal/neonatal alloimmune thrombocytopenia: refer after confirmation of pregnancy.

F. Teratogens F. Three months prior to conception or any time during pregnancy, refer for exposure to such medications as hydantoin (Dilantin), carbamazepine (Tegretol), valproic acid (Depakene), isotretinoin (Accutane), , or excessive radiation greater than 6 rads.



6. Antiphospholipid syndrome 7. Systemic lupus erythematosus 8. Hyperthyroidism (poorly controlled)

9. Hemoglobinopathies (hemoglobin SS, SC, or S-thalassemia) 10. Maternal cyanotic heart disease 11. Chronic renal disease 12. Oligohydramnios (unless recommended otherwise by MFM) 13. Polyhydramnios (unless recommended otherwise by MFM) 14. Red cell alloimmunization (not receiving intrauterine transfusions) 15. Previous third trimester fetal demise 16. Cholestasis of pregnancy 17. Fetal anomalies at risk for stillbirth (MFM faculty approval required) 18. Monochorionic/diamniotic twin gestation 19. Unexplained elevation of MSAFP (MoM >2.5) with normal targeted ultrasound

10 Protocol Development Team

Name Affiliation

*Mark Hernandez, MD Chief Medical Officer

Community Care Collaborative

*Ted Held, MD

Associate Chief Medical Officer

and Clinical Champion

Community Care Collaborative,

People’s Community Clinic

Amy Young, MD, Chair of Women’s

Health

Dell Medical School at UT Austin

John Gianopoulos, MD, VP of

Women’s Health Services

Seton Healthcare Family

Ashley Choucroun, MD, Service

Line Director Women’s Health

CommUnityCare

Bri Tristan, MD El Buen Samaritano

David Billue, MD Lone Star Circle of Care

Curk McFall, MSN, RN Community Care Collaborative

Andrea Guerra, MPH Community Care Collaborative

Darlene Lanham, M.P.Aff. Community Care Collaborative



11 References

12 Glossary of Abbreviations

Abbreviation Term

A2 DM White’s Classification of Gestational Diabetes Mellitus (GDM) A2 DM = Abnormal OGTT, requires medication for glycemic control (oral agent or insulin)

APRN Advanced Practice Registered Nurse

BP Blood Pressure

CF Cystic Fibrosis

CNMs Clinical Nurse Mid-Wives

EGA Estimated Gestational Age

FTA-ABS Fluorescent Treponemal Antibody-Absorption Test

GTT Glucose Tolerance Test

Hct Hematocrit

Hgb Hemoglobin

H/O History of

MFM Maternal Fetal Medicine

MHA-TP Microhemagglutination Assay

MoM Multiples of Median

MSAFP Maternal Serum Alpha-Fetoprotein

RN Registered Nurse

SMCA Seton Medical Center Austin

TP-PA Treponema Pallidum Antibody

classification: internal use only · and positive confirmatory mha-tp, fta-abs, or tp-pa. b....

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