Documente Academic
Documente Profesional
Documente Cultură
Prenatal Care
Prenatal Care
Practices to continue
Underperformed practices
Vaccination for influenza: during any trimester
Smoking cessation:
Where is the Evidence for What
We Do? Michael Policar, MD, MPH
@ OBGYN UCSF
Prenatal Care
Prenatal Care
Preconception counseling:
Folic acid: 50-70% risk reduction for NTD.
Control of blood sugars & pressures
(Avoid contraindicated medications).
Dietary control for women with
phenylketonuria.
CDC recommended
V26.49 (procreative management
counseling)
parvovirus,
or toxoplasmosis;
NO routine
multivitamins
(multiv
onlypoor
for
women with
multiple gestations,
smokers,
vegetarians,
and itamins
those with
diet).
11/8/2012
Prenatal Care
Questionable Value?
Practices to continue:
Blood pressure:
R/o chronic hypertension at initial visit
Screen for preeclampsia after 20 weeks
Screening:
Initial visit prenatal laboratory examination
2nd and 3rd trimester labs
Prenatal Labs
at First OB visit
Pregnancy Test
Home-based pregnancy test:
1 day after missed menses: ~50% negative
1 week after missed menses: ~100% positive
Expected Result
Rh and Ab screen
Rh +/-; negative
Alloimmunization
H/H
> 11.5 g/dL
Anemia
Rubella/Varicella
Immun
MCV
> 80 fL
IgG
e
Hemoglobinopathy
PAP
Cervical cancer
Normal cytology
Urine Culture
Asx Bacteriuria
Negative
Syphilis testing
Treatment
Negative
HBsAg testing
Prev transmission
Negative
Chlamydia testing
Treatment
HIV testing
Treatment
Clinical Utility
A, B, AB, O
Negative
Negative
Exposure/pp
vaccine
11/8/2012
Blood Type
& Antibody
Screen
Refractorin
ess to
platelet
transfusion
therapy
Hemolytic
risk of venous thromboembolic disease than those of
disease of
newborn
(HDN)
ABO
incompatibil
ity in 15 %
of
pregnancie
s
Results
in HDN in
only 0.6%
Rh blood group
Disease
associations
Subjects
with phenotypes:
blood groups A, B, or AB have a higher
Most
common
Rh + or Rh
Technically correct nomenclature:
Rh(D) positive or Rh(D) negative.
Rh blood group
Caucasians.. DCe
blood
group O (RR = 3.7)
African-Americans.. Dce
Anti-Rh(D) immunoglobulin
Sterile solution containing IgG anti-D (anti-Rh) manufactured
from human plasma (not recombinant).
Many brand names:
HyperRHO
RhoGAM
Rhophylac
WinRho
11/8/2012
Anti-Rh(D) immunoglobulin
When & how much?
Unsensitized Rh(D) negative pts should be
offered it at 28 wks.
Optimum dose regimen in the US is 300 g.
A single 300 g dose suppress the immune
response to 15 mL of Rh-positive red blood
cells (30 mL Rh(D)-positive fetal whole
blood).
Reduces the incidence of antenatal
alloimmunization from 2% to 0.1 %.
Anti-Rh (D)
immunoglobulin
Miscarriage, abortion, ectopic pregnancy, multifetal
Increased
of Feto-Maternal
(FMH):
abdominal risk
trauma,
external cephalic Hemorrhage
version, antepartum
reduction, amniocentesis, chorionic villus sampling, blunt
bleeding, and fetal death.
with intermittent vaginal bleeding
What if there is an ongoing risk for FMH?
such as chronic placental abruption or placenta previa
every three weeks with repeat dosing if Coombs negative.
Serial determinations of the maternal indirect Coombs
Anti-Rh(D) immunoglobulin
Anti-Rh(D) immunoglobulin
After delivery:
maternal
in the
maternal blood in the first trimester (> 10 wks)
11/8/2012
cffDNA
Collection
Sample
Sample type
Whole blood
positive
antibody
Previous history
of an affected
fetus?
YES:
SensiGene
Fetal RhD genotyping
(EDTA lavender
top)
Whole blood
cell-free DNA)
EGA (wks)
> 10 wk
10 wks
2 x 10 mL tubes
2 x 10 mL tubes
Collection requirements
screen
Antibody
Storage/shipment
Turnaround time
10 business days
Do not freeze/
Do
Cost to patient if
$ 235
(commercial PPO)
$ 25
Pre-
authorization (others)
positive antibody
Critical antibody titer ( 1 in 16) refer to MFM
screen
Copyright 2012 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins.
30
11/8/2012
Hemoglobin
Hemoglobin
High Hemoglobin
Objectives:
Differential diagnosis:
Detect anemia
High altitude
Low hemoglobin =
Anemia
Anemia in pregnancy:
First and third trimester:
Hb levels <11 g/dL and Hct levels <33%
Second trimester:
Hb levels <10.5 g/dL and Hct levels <32%
Folate deficiency
Alcoholism
Liver disease
Hypothyroidism
Myelodysplastic syndromes
Aplastic anemia
Medications (AZT, INH, MTX, Bactrim)
11/8/2012
Ferritin
Celular storage protein for iron.
Correlates well with total-body iron stores.
Best single test to make dx of IDA: < 12 g/L
Differentiates IDA from chronic disease
Elevated ferritin:
Acute-phase reactant
Iron overload states
Low ferritin:
IDA
Mentzer Index:
MCV/RBC count < 13 favors
thalassemia over IDA
Check Ferritin
IDA -
Management
Rx? or w/u
electroph)?
l
9-11
ow MCV
n
no response
Rx: iron x 1 month
(ferritin Hb
<9
w/u & Rx
Hemoglobinopathies
Peripheral smear
Reticulocyte count
Direct Coombs
Hematology consult; bone marrow exam?
disease,
endocrinopathy,
(acute
or malignancy,
chronic), chronic
renal failure,marrow
kiver
aplasia, etc.
11/8/2012
What if patient is
Multiethnic?
Parent history:
History of anemia
Previous stillbirth
Hemoglobin
Electrophoresis
Hb A2 > 3.5% and
Identifies 4 groups of patients:
Family history:
Hemoglobinopathy or thalassemia
Consanguineous marriages
Maternal MCV:
MCV <80 fL in the absence of iron deficiency
suggests thalassemia
Further testing with hemoglobin electrophoresis is
indicated.
counseling
If both are carriers Genetic
Fetal Risk
Electrophoresis or solubility
test?
If electrophoresis first:
Be aware of uncommon hemoglobins that migrate
similar to hemoglobin S but do not sickle
(hemoglobins G, D, and Lepore).
Needs then solubility test.
If solubility first :
It only detects hemoglobin S.
Needs then electrophoresis.
Normal
ironethnic
studies:
possible
-Thalassemia
Asian;
in high risk
groups.
Thus,
treat IDA first;(SE
then
Low iron studies: Cannot exclude -Thalassemia minor
Other
hemoglobinopathies: AS, AC, AD, AO, AE,
repeat electrophoresis.
Ethal, others
Couple at-risk of
fetal
Prenatal
available
hemoglobinopathy
DNA-based testing for hemoglobinopathies
can be performed during:
First trimester of pregnancy: CVS
(Chorionic Villus Sampling; 10 to 13 weeks)
Second trimester: Amniocentesis ( 16 weeks)
Sexually
Transmitted
Disease
Screening
11/8/2012
Estimated
Syphilis
Chlamydia
100,000
Gonorrhea
13,200
Hepatitis B
16,000
HIV
6,400
Syphilis
< 1,000
Objective:
Prevent in utero transmission of asymptomatic
infection which can lead to congenital syphilis
Total rate of Congenital Syphilis: 8.7 cases per 100,000
live births
11/8/2012
Treponema pallidum
Cannot be cultured in vitro
Suspicious lesion (chancre or condylomata lata):
Darkfield microscopy
Direct fluorescent antibody (DFA)
order
Definitive
Treponemal
used for(MHA-TP,
confirmation
antibodies tests
to T. pallidum
TP- of positive
PA)
higher
Microhemagglutination
or indirect
hemagglutination
assay for
rates of false positives
than
TP-PA
(ELISA)
Fluorescent treponemal antibody absorption assay (FTA-Abs):
Diagnosis of Syphilis
11/8/2012
= Discordant result
RPR
?
or
T. pallidum IgG
Ab ?
Discordant Results
Reverse from
Sequence Syphilis
Traditio
nal
Screening
EIA/CIA
+
RPR
versu
s
New
EIA/CIA
TP-PA
TP-PA
RPR
32 %
were false
(Reverse
57 %
Sequence)
Screenin
discor
dant
g?
Syphilis
is unlikely*
11/8/2012
HIV screening
HIV
Avoiding breastfeeding
When to start
antiretrovirals?
In antiretroviral naive patient:
It depends
CD4-cell count
HIV RNA levels
Hyperemesis in 1?
11/8/2012
Institute of Medicine
Hepatitis B
2010 report:
Most OBs screen for hepatitis B.
Most OBs advise that newborns of +HBsAg
mother receive both hepatitis B vaccine and
hepatitis B IV IgG immediately after birth.
However . . .
Only 1/2 -1/3 referred pregnant +HBsAg pt. to
specialist for management of Chronic Hepatitis
B.
Only few follow a systematic approach.
11/8/2012
Negative HBsAg
Risk factors for acquiring HBV during pregnancy:
Consider vaccination
(antepartum)
Courtesy Drs. Spach & Kim
Positive HBsAg
HBsAg
(+)
Apuzzio J, C
et al (Hepatitis B Foundation) The Female
Patient, April
o 2012
p
y
r
i
g
h
t
C
2
0
1
2
,
F
r
o
n
t
l
i
n
e
Positive HBsAg
Positive HBsAg
d
Recent meta-analysis concluded
that
i
lamivudine administeredca in the 3 might
l
prevent HBV transmission.
C
o
m
m
u
n
i
c
a
t
i
o
n
s
,
I
n
c
.
http://
www.
hepb.
org/pd
f/Final
_OB_
11/8/2012
Chlamydia &
Gonorrhea
Ophthalmia neonatorum
Neonatal pneumonia
Thus,
If +: Test of cure in 3 weeks and rescreen in 3.
If - : Retest women aged 25 years and those
at increased risk for chlamydia (e.g., women
who have a new or more than one sex partner).
Disease
Antibiotic
Chancroid
Azithomycin
Granuloma Inguinale
Azithomycin
LGV
Erythromycin
Syphilis
Penicillin
Chlamydia
Azithomycin
Gonorrhea
Ceftriaxone
HIV
Bacterial vaginosis
Antiretrovirals
Metronidazole
Trichomoniasis
Hepatitis B
toV specialist
V
Candidiasis
azoles
Genital Warts
Pediculosis
Scabies
Metronidazole
Refer
Topical
N/A
Permethrin
Permethrin
11/8/2012
Cervical Cancer
Cytology
Screening
Screening Methods
Consensus
(Nov
New
guidelines apply to pregnant women:
2012)
< 21 yr of age: NO screening
21 to 29 yr of age: Every 3 yr (cytology alone)
> 30 yr of age: cytology & HPV co-testing q 5 yr
or cytology alone q 3 yr (acceptable)
11/8/2012
HGSIL in Pregnancy
STD screening
What if patient requests anonymous testing?
Urine Tests
11/8/2012
Urine Dipstick
Asymptomatic Bacteriuria
Proteinuria:
Dipstick is non-reliable
Random urine P/C ratio
24 hr urine collection: gold standard
GBBS Bacteriuria
Symptomatic bacteriuria and Asymptomatic HIGH
colony counts ( 105 CFU/mL ) Treat.
GBS bacteriuria anytime in pregnancy should routinely
receive prophylactic intrapartum antibiotics (exception for
screening at 35-37 wks).
Antepartum LOW colony counts: < 105 CFU/mL:
Immunity to
Rubella &
Varicella
Determination of Immunity
Healthcare provider's diagnosis
Verification of history of disease
Document vaccination
Laboratory evidence of immunity (preferred)
For varicella if pt reports:
Positive history:
2%
Negative history:
7%
Susceptibility rates
Uncertain history:
17%
If Non-immune
(susceptible)
Avoid exposure sick individuals
Offer vaccination postpartum
If exposed to varicella during pregnancy:
IV Ig
Candidates
for passive immunization:
VariZIG
11/8/2012
Postexposure
Varicella
Prophylaxis with immunoglobulin
(VZV-specific
antibodies) is recommended compared with
watchful waiting.
Prophylaxis
In the U.S., VariZIG is the only available
product with VZV-specific antibodies (it is under
an Investigational New Drug application
Expanded Access Protocol).
Call 1-800-843-7477 (FFF Enterprises, California)
It should not be delayed for 10 days* after exposure
since efficacy beyond this time point is unknown.
No local IRB approval is needed.
MMWR Morb Mortal Wkly Rep.
2012;61(12):212
MMR Susceptibilities
Measles: 17%
Mumps:
16%
Rubella: 9%
33% susceptible to at least on of these viruses
< 2% susceptible to all 3.
Rubella Postpartum
Vaccination
Give
MMR
MMRV
months
postor
vaccination
Traditionally, it was advised to avoid pregnancy for 3
ACIP (CDC) has shortened it to 28 days
between
wkreported/confirmed
and 6 wk after conception.
There
are2no
congenital Rubella
syndrome cases in infants born to mothers vaccinated
Immunizations
General principles
11/8/2012
Tdap advertisement
References:
US:
ACOG: www.acog.org
DOD/VA:Guideline
The Management
of Uncomplicated
Pregnancy W
orking Group. Clinical
Practice
for the Management
of Uncomplicated
Pregnancy.
CDC: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
Institute for Clinical Systems Improvement
(ICSI):
http://www.icsi.org/prenatal_care_4/prenatal_care
routine
full_version
2.html
Notes
Notes