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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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