2016 FMF

What Should I Know

About Prenatal Care If I

Don’t Deliver Babies?

William Ehman MDVancouver, B.C.

11:15 to 11:45.

Thursday, November 10th, 2016

Learning Objectives

1. Provide the essential advice for woman

planning pregnancy

2. Identify currently recommended early

pregnancy tests

3. Correctly identify the expected date of delivery

4. Provide up-to-date counselling regarding the

recommended options for genetic screening

5. Discuss Immerging antenatal assessment

options

Disclosure

None

I am thinking about

getting pregnant, any

recommendations?

Newsweek; Sept.1999

Time, Oct. 2010

Why is Prenatal Care Important?

Developmental Origins of Health & Disease

Adverse

Pre-pregnancy

health

Adverse

Intrauterine

EnvironmentAdult Disease

CHD, Stroke,

Hypertension

Insulin resistance

Dyslipidemia

Anxiety/depression

Adverse

Postnatal

Environment

%

Birthweight

Prevalence of

future diabetes

• Genome

▫ complete set of DNA

• Epigenome

▫ compounds - modify, or mark the genome

altering activity of genes without changing the

order of DNA sequence

▫ the marks can be passed on from cell to cell &

from one generation to the next

Epigenetics:- “The study of gene

expression causing phenotypic effect”

PSBC Guideline Maternity Care Pathway 2010

Where Optimal Prenatal care starts:

• Preconception

Why?

• 40% unplanned (50% contraceptive failure)

• Early organogenesis

▫ Placenta at 7days

▫ neural tube closes @ 28days

• Influences future health

PSBC Guideline Maternity Care Pathway 2010

• The benefits of planned pregnancy

• Folic acid supplementation (0.4-5mg)

• Vitamin supplementation

• Healthy diet

• Food safety: to reduce food acquired infection

• Weight management (ideal BMI 19-27);risk of underweight, overweight,

obesity

• Physical activity

• Contraception choices for timed pregnancy

• Genetic counselling/testing (e.g. Ashkenazi Jewish Panel, Thalassemia,

Sickle Cell anemia

• Use of medications and supplements

• Lifestyle: including smoking cessation, alcohol, substance use

• History of communicable disease: e.g. rubella, varicella, STI, HIV, HSV

• Healthy sexuality

• Assess the Impact and identify additional resources (if needed) for:

• chronic medical/mental health conditions: pre-pregnancy planning

• past gynecologic history (e.g. cone bx, PCOS)

NTD Prevention

• Failure of neural tube closure in 3rd – 4th wk after

conception (day 26 - day 28)

• Folic acid with multivitamins reduces:

▫ NTDs

▫ heart defects

▫ urinary tract anomalies

▫ oral facial clefts (and palate)

▫ limb reduction defects

• **Advise all fertile women; folic acid in vitamin pillSOGC CPG Pre-conception folic acid May 2015

Folic Acid: New Recommendations(?folic acid ↑resp. inf. & asthma in children)

Low risk:

Moderate risk:• Medication (epileptic, metformin,

Sulfasalazine, trimethoprim, triamterene,etc.)

• NTD in 1st/2nd degree relative woman/partner

• GI disease (Celiac, IBD), liver, dialysis,

alcohol

• Prior folate sensitive affected infant(cleft,

cardiac, limb)

High risk:• Personal or previous infant

(woman or partner) with NTD

0.4mg/d x 3mon prior

1mg x 3mon

prior →12wks then 0.4/d

4mg x 3mon

prior→ 12wks then 0.4(or5)/d

SOGC CPG May 2015

• Multivitamin

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

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

• Vit. D - 400-2000 IU/d

• Deficiency

▫ Risk factors: melanin, sun exposure, dairy intake

▫ Outcomes: fet.growth, ossification/enamel, cardiomyopathy

• ?400 vs. 4,000 IU in TM 2&3 GDM, preeclampsia and PTB2

• Vit. C – 500 mg/d supplementation in pregnant smokers• improved NB PFT’s & wheezing through 1 yr

• Calcium – 1000 mg/d

Preconception/Prenatal - Supplements

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

3McEvoy, RTC n=159; JAMA, May 18, 2014

IRON• pregnancy need is ~ 27 mg/d

• North American diet = 15mg/d

• Most require15 to 20 mg supplement1

1Health Canada, 2010

150

108

65

35

0

20

40

60

80

100

120

140

160

PolysaccharideIron Complex

FerrousFumarate

Ferrous Sulfate FerrousGluconate

Elemental Iron Per Table

• 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:Listeriosis/Salmonella/Toxoplasmosis:

• 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 = 1501-2002-3003 mg

Caffeine

Foods and Beverages Caffeine

(mg)

Coffee (8 oz.)

Brewed, drip

Instant

137

76

Tea (8 oz.)

Brewed

Instant

48

30

Cola & caffeinated drinks (12

oz) 37

Hot cocoa (12 oz) 10

Chocolate Milk (8 oz) 8

1Motherisk2Food Standard Agency, UK3Health Canada, NICE 2008

Does Pre-pregnancy BMI (kg/m2) Matter?

OW/Obese (BMI>25&30)• Maternal: GDM, GH, TED, dystocia, C/S,

infection1

• Neonate: LGA, asphyxia, PNM,

congenital defects, BS, BR1

• “Even modest” BMI: PN mortality2

1Canadian Maternity Experiences Survey, 2009; 2Aune

et al JAMA 2014

Underweight

(BMI<18.5)• PTB, SGA,

Neonatal M&M,

adult illness1

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

• With 3 pregnancy losses:▫ 3.5% - 5% risk of maternal chromosomal rearrangement

▫ 1% - 2% risk of a paternal rearrangement.

Genetic screening & family history

Phenylketonuria Thrombophilia

Hemophilia A Muscular dystrophies

Cystic fibrosis Mental retardation

Tay-Sachs Hemoglobinopathies

Substance use:• Screen

• Council, refer

• Harm reduction

Medications:• Prescription

• OTCs▫ E.g. NSAIDs (not ASA) in early pregnancy:

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

Marijuana

• Fetal levels are 10% maternal

• Can take 30d for complete excretion

• Fetal effect:

▫ disrupt brain development/function

▫ Low scores visual problem solving, coordination

▫ Decreased attention span and school

performance

ACOG Committee opinion July 2015

Tobacco• Screen all1

Alcohol “insufficient evidence to define

any threshold for low-level

drinking in pregnancy.”2

2SOGC ‘10

1BCPHP Guideline 09

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

Infections• Screen for periodontal, urogenital, STIs

• Counsel re: TORCH

▫ Note: Rubella: adverse effects in 90% infants in 1st 10wks

• Hx of STI, substance use, Soc/Economic

herpes syphilistoxoplasmosis rubella CMV

Women Who May Need Additional

Care: Previous History• Recurrent miscarriage

• Preterm birth▫ e.g. previous PTB <34wks or Cx ≤ 20mm ≤ 24wk

Rx vag micr progesterone 16-20 wks to 36 wks

• Pre-eclampsia, HELLP syndrome or eclampsia▫ e.g. Rx ASA 81 mg & 1-2 g calcium

• Rhesus isoimmunization or other significant blood

group antibodies

• Gestational diabetes requiring insulin

• Puerperal psychosis

• Grand multiparity (≥5)

I am 7 weeks

pregnant, what

should I do?

Two resources

http://www.perinatalservicesbc.ca/health-professionals/professional-resources/health-promo/pregnancy-passport

http://www.perinatalservicesbc.ca/health-professionals/professional-resources/aboriginal-resources/pregnancy-passport

Essential Early Prenatal Care:

Time Sensitive!!

1.Folic Acid supplementation

2.Estimate due date

3.Screen/counsel

1. Medications, alcohol/tobacco/substance, genetics

4.Screening lab tests

5.Prenatal genetic screening for aneuploidy & US

offered to all

1. Folic Acid supplementation

• 0.4 – 4 (5) mg depending on risk factors

• “all women should be offered a fetal ultrasound between 11 and

14 weeks, to confirm viability, gestational age, number of fetuses,

chorionicity in multiples, early anatomic assessment, and NT

measurement (if accredited sonographer is available).”1

• Will reduce “post-date” inductions2

• Use earliest US > 7 wks (CRL=10mm)

2. Estimate due date

1SOGC Committee Opinion, 2016; 2SOGC 2008 3SOGC CPG, No. 303, 2014

• 7-23 wks US alone is more accurate than a

“certain” menstrual date.3

• A suggestion:

• If possible: approx. 9 wks to confirm EDD for

maternal serum screening.

3. Screen/counsel re:

▫ medications and supplements

▫ Alcohol; assess risk; cessation/reduction, local

supports/resources

▫ Tobacco: referral/nicotine replacement Rx(smoke >10

cig./day or not quit by 12 wks

▫ substance use. Referral/resources

4. Screen/Diagnostic Tests(0-14wks)

Test LOR

Blood Group, Rh, Antibodies C Hemolytic disease

Hb, MCV B Anemia, hemoglobinopathy

HIV 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 A

C

Early pregnancy - all

Recurrent 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

4. Screen/Diagnostic Tests(0-14wks)

Test LOR

Blood Group, Rh, Antibodies C Hemolytic disease

Hb, MCV B Anemia, hemoglobinopathy

HIV 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 A

C

Early pregnancy - all

Recurrent 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

0.1 to 2.5 mIU/L 1st TM

0.2 to 3.0 mIU/L 2nd TM

0.3 to 3.0 mIU/L 3rd TMRef. Thyroid disorders during pregnancy.

Yazbeck CF - Med Clin North Am - 01-MAR-

2012; 96(2): 235-56

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 Insufficient

PSBC Guideline Maternity

Care Pathway 2010

5. Prenatal genetic screening for

aneuploidy & US offered to all

“All pregnant women in Canada, regardless of age,

should be offered, through an informed counselling

process, the option of a prenatal screening test for

the most common clinically significant fetal

aneuploidies in addition to as second trimester

ultrasound for dating and assessment of fetal

anatomy, and detection of multiples. (I-A)*

*J Obstet Gynaecol Can 2011;33(7):736-750

2016

Prenatal

Aneuploidy

Screening

http://www.perinatalservicesb

c.ca/Documents/Guidelines-

Standards/Maternal/Prenatal

ScreeningGuideline.pdf

SIPS Serum Integrated Prenatal Screen

9-13+6 PAPP-A

15-20+6 AFP, uE3, hCG and inhibin-A

IPS Integrated Prenatal Screen

SIPS + NT: 11-136

QUAD One blood test

15-20+6 AFP, uE3, hCG and inhibin-A

NT Nuchal Translucency

11-13+6

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

Amniocentesis ≥15 wks

NIPT Non Invasive Prenatal Testing: ≥10 wks

Summary of Prenatal Genetic Screening

All

BC ≥35

≥14 wks

BC ≥35Multiples,

HIV, T21,

T18, IVF-ICSI

BC Prenatal Genetic Screening Program, PSBC January 2014

best 10-116

best 152-16

best 12-133

best 152-16

best 12-133

Non Invasive Prenatal Testing (NIPT):

cffDNA In Maternal Plasma

• Fragments of extracellular

cffDNA detectable by 4 wks

• cffDNA with gestation

▫ 10% total cfDNA by 7-10wk

▫ up to 50% by term

• Rapid clearance Post Partum (~1-2 h)

Sufficient

• “Real-time snapshot of fetal genetic status”

Prenatal Screening/Diagnostic

Applications of cffDNA

• Fetal autosomal

aneuploidies

• Fetal sex determination• X-linked disorders, etc.

• Sex-chromosome

aneuploidy

• Rhesus typing

• Single gene disorders• Huntingtons, achondroplasia, MD

• Microdeletion syndromes

• Whole fetal genome

sequencing

*

*Accurate dating is essential!BC Prenatal Genetic Screening Program, PSBC June 2016

Woman’s

age

Gestational Age at the First Prenatal Visit

≤ 13+6 wks 14 – 20+6 wks

No prior screening

≥ 21 wks

< 35 years • SIPS • (if patient is HIV+ & NT is

available, IPS)

• Quad • Detailed US

35 – 39yrs • IPS; or

• If NT N/A, SIPS

• Quad • Detailed US;

• & Amnio

40+ yrs • IPS; or

• If NT N/A, SIPS;

• Or CVS or Amnio

• Quad; or

• Amnio

• Detailed US

• & Amnio

NIPT: BC

Elligibility

• +ve SIPS, IPS or Quad screen for DS or T18

• Previous pregnancy with T21, T18 or T13

• Risk of T21, T18 or T13 >1/300 (based on screen & Us)

Screening options available through the BC

Prenatal Genetic Screening Program

*

*Accurate dating is essential!BC Prenatal Genetic Screening Program, PSBC June 2016

Woman

Gestational Age at the First Prenatal Visit

≤ 136 wks 14 – 206 wks ≥ 21 wks

Personal/ FHx risk

DS, T18, T13

• IPS; or

• NIPT; or

• CVS or Amnio

• Quad; or

• NIPT; or

• Amnio

• Detailed US &

• NIPT; or

• Amnio

Personal / FHx risk

chromosomal abn.

other than DS, T18

• CVS or Amnio • Amnio • Detailed US &

• Amnio

Twin gestation • IPS;

• or SIPS if no NT

• or if ≥ 35, Amnio

• Quad;

• Or If ≥ 35,

Amnio

• Detailed US

& if ≥ 35, Amnio

Pregnant following

IVF with

intracytoplasmic

sperm injection

• IPS

• or SIPS if no NT

• Or CVS or Amnio

• Quad; or

• Amnio

• Detailed

ultrasound; &

Amnio

Screening options available through the BC

Prenatal Genetic Screening Program

Aneuploidy Screening Across Canada

• It varies.

Alberta

Two options (gest. age

dependent)1. 1st TM screen(11w2-13w6)

a) NT

b) β-HCG & PAAP-A

2. Quad(15w0-20w6)a) αFP, uE3,hCG,DIA

Aneuploidy screening*• Saskatchewan: 1ST TM (PAPP-A & fßhCG)

▫ If high risk: NT if low risk Quad testing then report

• Manitoba▫ Nt if risk factors then blood test after 15 wks

• Ontario▫ IPS, SIPS, FTS, Quad

• Quebec▫ SIPS

• New Brunswick▫ SIPS, ?other

• Nova Scotia & PEI▫ SIPS and NT if risk factors

• Newfoundland▫ MSS

• Yukon, NWT▫ Uncertain

• Nunavut▫ Quad

▫ *As best as I could find in the internet!

Hypothyroid and Pregnant

• Women taking thyroid hormone:

▫ Will need due to TBG

▫ “should be advised to increase their thyroid

hormone dose by 2 extra tablets per week

immediately following a positive pregnancy test”

• Ideal TSH level:

▫ < 2.5 mU/L 1st TM, < 3 mU/L 2nd & 3rd TM

• TSH: q 6 wks or 4 wks after dosage change

• Remember:

▫ TSH may be low in 1st TM due to HCG : no

dose is needed if the fT4 & fT3 normalLochnan 2014, McMaster Plus

(0-14wks)

PSBC Guideline Maternity Care Pathway 2010

PSBC Guideline Maternity Care Pathway 2010

(0-14wks)

Pre-pregnancy

BMI category

Meana rate of weight gain in the

2nd and 3rd trimester

Recommendedb range of total

weight gain

kg/week lb/week kg lbs

BMI < 18.5

Underweight0.5 1.0 12.5 - 18 28 - 40

BMI 18.5 - 24.9

Normal weight0.4 1.0 11.5 - 16 25 - 35

BMI 25.0 - 29.9

Overweight0.3 0.6 7 - 11.5 15 - 25

BMI ≥ 30c

Obese0.2 0.5 5 - 9 11 - 20

WEIGHT GAIN (SINGLETON)

a Rounded values.b Calculations assume a total of 0.5 - 2 kg (1.1 - 4.4 lbs) weight gain in the first trimester.c A narrower range of weight gain may be advised for women with a pre-pregnancy BMI of

35 or greater. Individualized advice is recommended for these women.Health Canada Gestational Weight Gain Recommendations

15

12.5

10

7.5

http://www.healthcanada.gc.ca/f

oodguide

calories:

TM Cal.

2nd 350

3rd 450

Breast

feed

350

- 400

Hot Tubs/Baths• water temp < 39 ℃ 3

Stretch marks• Prevention: nothing proven

▫ May harm: Retinoids, Salicylic acid,

Soy(chloasma)

INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT

1Institute for Clinical Systems Improvement, 13th Ed. Aug. 20092 AAP 1997, 3 ACOG

Work – risk factors1

• 36 hrs/wk or 10 hrs/day

• standing(>3-6h/shift), heavy lifting

• mental stress

• noise: LBW,PTB,hearing loss2

▫ avoid prolonged exposure to low-frequency

sound levels (<250 Hz) above 65 dB during

pregnancy

▫ Not louder than 115 dBA after 20-24 wks

INSTITUTE FOR CLINICAL SYSTEMS IMPROVEMENT

1Institute for Clinical Systems Improvement, 13th Ed. Aug. 20092 AAP 1997

Dental and Periodontal Care

• Safe

• Some evidence that

“periodontal treatment

may have an effect on

reducing preterm birth”*

*Antenatal care

Evidence Update May 2013

Exercise• “All without contraindications encouraged to participate in

aerobic and strength-conditioning exercises” (II-1, 2B)1

• “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°

• “reduces risk of cesarean delivery.”3

Absolute Contraindications Relative Contraindications

Ruptured membranes Previous spontaneous abortion

Preterm labour Previous preterm birth

Hypertensive disorders of pregnancy Mild/moderate cardiovascular disorder

Incompetent cervix Mild/moderate respiratory disorder

Growth restricted fetus Anemia (Hb <100 g/L)

High order multiple gestation (≥ triplets) Malnutrition or eating disorder

Placenta previa after 28th week Twin pregnancy after 28th week

Persistent 2nd or 3rd trimester bleeding Other significant medical conditions

Uncontrolled type 1 DM, thyroid, CV, Resp. Disease or systemic disorder

1SOGC CPG No. 129, June 2003

(Canadian Society for Exercise Physiology)2http://www.healthypregnancybc.ca/page194.htm

3Domenjoz, Am J Obstet Gynecol. 2014

The Model of Care

16w

41w40w39w38w37w

36w34w32w30w

28w24w

Memorandum on Antenatal Clinics UK

Min. of Health, 1929

Traditional

A New Model of Care?

By 11-13 weeks,

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: maternal history,

serum tests, US

Specialist care

12-34w

20w

37w

41w

From Nicolaides K, Prenat Diagn 2011

Today’s Model of Care

As early as

possible

Postpartum

Delivery

Resources…..

• http://www.perinatalservicesbc.ca/health-professionals/professional-resources/pathways-

toolkits/maternity-care-pathway

Thank you

William Ehman MD