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Early Prenatal Care Tips for Primary

Care

Brittany BarronStacy Desilets

Presenters

• Dr. Brittany Barron – Rural Family Physician in Temiskaming Shores, low risk obstetrics for 1.5 years

• Dr. Stacy Desilets – Rural Family Physician in Temiskaming Shores, low risk obstetrics for 11 years

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Disclosures

We have received no funding related to products or investigations discussed in this presentation.

We will each receive a speaker stipend from the SRPC for being here today.

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Objectives

1. Provide high quality prenatal care for women in first and second trimester

2. Identify women who would benefit from ASA supplementation in pregnancy

3. Explain first and second trimester genetic screening to pregnant patients

4. Organize evidence based investigations for women in early pregnancy

5. Counsel pregnant patients on safe exercise, weight gain, medications, and work plans in pregnancy

PRECONCEPTION(WE SHOULD BE SO LUCKY!)

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Pre-Conception• Some women will see their PCP

BEFORE they actively try to conceive

• Use this appt to educate re: lifestyle, smoking cessation, ideal BMI, Folic acid/calcium/iron, exercise, cannabis

• identify risk factors (health and social/work)

Pre-Conception• Pap needed?• Labs (as indicated): anemia,

?Rubella and varicella status, pre-existing diabetes

• Update immunizations: MMR (if needed), flu shot, Adacel - should wait until 21 weeks

• Review previous pregnancies –risks for recurrent losses

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FIRST TRIMESTER

• Complete Perinatal Records –province specific

• Each question on the antenatal record is there for a reason- be sure to UNDERSTAND why we ask certain things, or test for certain things. Could this pregnancy be at risk due to pre-existing maternal factors? Previous OB Hx?

The First Prenatal Visit

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The First Prenatal Visit

Investigations for First Trimester

• Dating ultrasound

• Public health labs (Hep B, HIV, VDRL, Rubella)

• Routine labs – CBC, bloodtype, urine culture, C&G

• Discuss genetic screening

• ASA – yes or no

Reduce risk of eclampsia

• 75-160 mg ASA from T1 until 36 weeks • benefits only if started BEFORE 16 weeks

– previous pre-eclampsia or gestational HTN– pre-existing hypertension– pre-gestational type 1 or 2 diabetes– Multifetal gestation– Chronic Kidney disease– Autoimmune disease

ASA shown to reduce pre-eclampsia/eclampsia, premature birth, IUGR

Who needs ASA??

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May also consider if multiple moderate risk

Factors• Nulliparity

• BMI >30

• Family history of pre-eclampsia

• Previous Adverse Pregnancy Outcome

• Age >35

• >10 yr pregnancy interval

• Previous IUGR/SGA

Who needs ASA??

Not-so routine dip?

• Urine protein is a non-reliable predictor of preeclampsia & health outcomes, BP is the better screening tool

• Recommended one screen in 1st T with a urine culture for asymptomatic bacteriuria– Applies for women who are not at

increased risk for asymptomatic bacteriuria

What about urine??

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GBS bacteriuria • Recommended treatment of >/=10x5

cfu/ml. If asymptomatic & < 10x5, no treatment.

• If GBS + urine during pregnancy, should receive GBS prophylaxis during labour. No need to do GBS swab.

Urine Chlamydia & Gonorrhea Screen• 1st PN visit & each trimester based on risk

factors• If STI treated, test of cure for both partners

What about urine??

• Must be done accurately in 1st trimester; LMP and dating US (resource dependant)

• has implications for – prenatal screening tests

– timing for: morphology scan, screening for GDM, GBS screening

– Size discrepancy (IUGR vs LGA vs wrong dates!)

– Post-dates planning

• See SOGC Clinical Practice Guideline –Determination of Gestational Age by Ultrasound, No. 303, Feb. 2014

Dating the Pregnancy

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Prenatal Genetic Screening

5 options in Canada- Screen for Trisomy 21, 18, 13, open NTD

1. Maternal Serum Screening2. First Trimester Screening3. Integrated Prenatal Screening4. Enhanced First Trimester Screening5. Non-Invasive Prenatal Screening

These are all SCREENING tests Diagnostic tests are Choriocentesis

and Amniocentesis

Prenatal Genetic Screening

Serum Markers (alphabet soup!)• PAPP-A – Low in Down Syndrome

• uE3 – made by placenta, Low in trisomies

• B-hCG – High in Down Syndrome

• AFP – made by yolk sack, High in NTD, Low in trimsomies

• PlGF – Low in Down Syndrome

• Inhibin-A – elevated in Down Syndrome

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Prenatal Genetic ScreeningScreening Test

Serum Markers Gestational Age

MSS AFP, uE3, B-hCG 15w – 20w+6

Quad screen AFP, uE3, B-hCG, inhibin -A

15w - 20w+6

FTS PAPP-A, B-hCG 11w – 13w+6

IPS (2 steps) 1 - PAPP-A, NT2 - uE3, B-hCG, Inhibin-A, AFP

1. 11w-13w+62. 15w-18w-6

SIPS (no NT) As above – no NT As above

Enhanced FTS PAPP-A, AFP, B-hCG, PlGF, NT

11w -13w+6

eFTS (no NT) As above, no NT As above

NIPT Cell free fetal DNA Over 10 weeks

Screening Test Detection Rate False Positive Rate

MSS 75-85% 5-10%

FTS 78-90% 8-9%

IPS (2 steps) 85-90% 2-4%

SIPS (no NT) 80-90% 2-7%

Enhanced FTS 85-90% 3-6%

eFTS (no NT) 80% 5%

NIPT 98.5% 0.02%

Efficacy of Screening

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Prenatal Genetic Screening

Non Invasive PrenatalTesting (NIPT)

No serum markers – use cell free fetal DNA that is circulating in

maternal serum

NIPT-Non-invasive prenatal testing

• “Panorama” or “Harmony”

• Available very early in preg (>10 weeks)

• As a screen or as second tier for positive FTS

• Usually self pay, appx $500-$900

• Gender and many other genetic anomalies

No risk of fetal loss but still

just a SCREEN!

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Ontario Lab Requistion for Prenatal Screening

Invasive prenatal testing

• Amniocentesis– Small amount of amniotic fluid extracted with

needle; >15wks gestation– Added low risk of miscarriage 0.5-1.0%

• CVS– Sample of placental tissue extracted; 10-13 wks– Added low risk of miscarriage 1-2%– Allows earlier diagnosis & decision

• Specialized Genetic Testing

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Prenatal Screening by Province

Province Prenatal Screening offered

British Columbia/Yukon

All women – SIPS or MSS, high risk IPS, Very high risk – NIPT (Yukon same)

Alberta All Women – FTS or MSS if late

Saskatchewan Early – early – FTS + AFP (if + add NT), late- Quad

Manitoba All women MSS, high risk get NT – if + referral to genetics for ? NIPT

Ontario eFTS if early, MSS if late, NIPT for any positiveHigh risk – NIPT at 10 weeks

Quebec All women SIPS – may pay for IPS, MSS if late

Maritime Provinces Early – SIPS, late MSS, high risk sent to “Early Pregnancy Review Clinic” (EPR)

North West Territories ??

Nunavut MSS for all, if + amnio + high level US

Second Trimester

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16-22 weeks Dating US – if not already doneeFTS results or MSS

Consider NIPT or referral

Anatomy US 18-22 weeks

? Gender

Placental placement

Fetal morphology/anomaliesOpen neural tube defect

Consider referral for high risk

26-30 Weeks• CBC - anemia• Antibodies – Rhesus negative

– RhoGAM/WinRho injection

• Diabetes Screening– 50 gram OGCT (24-28)

– 75 gram OGTT

• Referral to OB Provider– Community specific

– Earlier if complications

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Third Trimester

30 - 36 Weeks• GBS swab• HSV serology/prophylaxis• Vaccinations

– Influenza – when available

– Pertussis 21-36

• Steroids for high risk• US for position or growth – as

indicated• Fetal Kick Counts as needed

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General Discussion Topics

Weight GainExercise

Work PlansMedication

Guidelines for Gestational Weight Gain

Pre-pregnancy BMI < 30 to decrease risks

- Maternal: Gestational DM, future Type 2 DM, sleep apnea, pre-eclampsia- Fetal: LGA, preterm birth, stillbirth, congenital anomalies, future risk obesity, DM,

heart disease

Pre-pregnancy BMI >18 to decrease risks

- LBW/IUGR, preterm birth, breastfeeding difficulties

Pre-pregnancy BMI kg/week Total weight gain in kg

<18.5 0.5 12.5-18

18.5-24.9 0.4 11.5-16

25-29.9 0.3 7-11.5

>30 0.2 5-9

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Exercise in Pregnancy

Safety of Exercise in Pregnancy

PA should be considered a front line intervention to reduce pregnancy complications & improve maternal physical and mental health.

Maternal:decreased pre-eclampsia, GHTN, GDM, c/s, OVD, excessive weight gain, urinary incontinence, depressionFetal:LGA

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Exercise in Pregnancy- Contraindications

Absolute

• ruptured membranes • premature labour• unexplained persistent vaginal

bleeding• placenta previa after 28 weeks

gestation• preeclampsia• incompetent cervix• intrauterine growth restriction• high-order multiple pregnancy

(e.g., triplets)• uncontrolled Type I diabetes, HTN,

thyroid disease• other serious cardiovascular,

respiratory or systemic disorder

Relative

• recurrent pregnancy loss• gestational hypertension• a history of spontaneous preterm

birth• mild/moderate cardiovascular or

respiratory disease• symptomatic anemia• malnutrition• eating disorder• twin pregnancy after the 28th week• other significant medical conditions

PAR-Med X for Pregnancy

http://www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf

Exercise in Pregnancy

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Working in Pregnancy

• Routine discussion about issues in uncomplicated pregnancies (poor sleep, discomfort, fatigue) to help plan for work cessation

• Health related vs. illness related leave of absence

• Support health related leave of absence for delivery preparation

• Maternity benefits can begin within 8 weeks before the onset of labour

• HCP cannot support an illness-related leave in an uncomplicated pregnancy

Medications in Pregnancy

http://www.motherisk.org/

Pain:• Acetaminophen = safe• NSAIDS = only safe in 2nd T

Heartburn:• Avoid bismuth subsalicylate

(pepto bismol)• Safe: calcium carbonate (tums),

ranitidine, PPIs

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Medications in Pregnancy

Cough/cold:• Avoid phenylephrine,

pseudoephedrine & guaifenesin in 1st T

Asthma:• Mostly safe

Allergy: • Diphenhydramine & second gen

anti-histamines are safe

Mental health:• Lithium

– avoid if possible, esp first trimester

• Second Generation Antipsychotics– No increased risk congenital malformations– No increased risk of miscarriage, still birth– Case by case basis, lowest effective dose

• SSRIs, SNRIs– Generally safe – Lowest effective dose advised– Avoid paroxetine

Medications in Pregnancy

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Antibiotics:• No congenital malformation: cephalosporins,

PCNs, erythromycin, clindamycin, metronidazole • Miscarriage? First trimester use of: macrolides*,

quinolones, metronidazole, tetracyclines, sulfonamides

• Known teratogenic effects:– aminoglycosides - risk of fetal & mat ototoxicity &

nephrotoxicity– Tetracycline/doxycycline - fetal teeth & bone

discolouration. – Fluoroquinolones - avoid – Sulfonamides, nitrofurantoin - avoid 1st T

Medications in Pregnancy

Yeast infections:• High dose fluconazole (400, 800 mg) is

teratogenic• Topical clotrimazole or miconazole PV x 7

days safest

HTN:• Ace inhibitors - increased risk of birth

defects• Safe: labetalol, nifedipine, methyldopa

Medications in Pregnancy

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Acne:• AVOID isotretinoin, tazarotene • Safer: erythromycin (PO/top), topical

clindamycin

Seizures:• Valproic acid - increased risk of birth

defects

Medications in Pregnancy

Final Message

• Prenatal care in FM can be challenging but many rewards

• High quality prenatal care improves maternal and fetal outcomes and is in the scope of practice for all family doctors.

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Questions??

swoods@nosm.ca

drbrittanybarron@gmail.com

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