DFCM ROUTINE PRENATAL CHECKLISTthehub.utoronto.ca/family/wp-content/uploads/2016/... · Smoking is associated with spontaneous abortion, preterm labour, premature rupture of membrane,

DFCM ROUTINE PRENATAL CHECKLIST

Dr.SharonDomb 1RevisedNovember2018–Dr.N.Gelber,Dr.S.Domb,Dr.M.Shuman

TimePeriod DiscussionTopics ChecklistPreconception • Nutritionandweightgain1

• Exercise2• Smoking/EtOH/MJ/drugs/caffeine3• Prescriptionmedications4• Workexposure(i.e.radiation,toxins)• FHxcongenitalanomalies/hereditaryd/o5

o CheckRubella±Varicellaimmunity6o CheckHIV7o Recommendfolatesupplementation8o Maternalage≥40àdiscussrisks9

Firstprenatal • Abovetopicsifnotdiscussed• Prenatalscreening10• Risksofinfections11• Nauseaandvomitingofpregnancy12• IndicationsforlowdoseASA13

o CompleteAN1o ScheduledatingUSifLMPuncertain14o ScheduleNTat11-13+6weekso GiveeFTSrequisition/NIPTo Giverequisitionfor1sttrimesterBW15(CBC,group&screen,ferritin,TSH,VDRL,HBsAg,rubellaAb,varicellaAb,Urinedip/urinalysis,C&S,Chlamydia,GC)16

o AddtestingforA1c/FPGifatriskforDM17o Consideraddedtestsifhigh/geneticrisko Fluvaccine(seasonal)18

Prenatalphysical(12weeks)

• TOLACifapplicable19

o Papsmearifdueo BVswabifsymptomaticorhighrisk20o ScheduleanatomyUS(18-22wks)

16-20weeks • Review1sttrimesterUSandlabresults• Recommendprenatalclasses• Quickening(onsetofFM)• Reviewscreeningresults(call)

o DiscusswhentocontactMD21o CorrectEDDbasedon1sttrimesterUS

20-27weeks • ReviewanatomyUSresults22• Cordblood23

o ObtainconsentandsubmitorderforRhIgforRh-vewomen24

o Provide2ndtrimesterrequisition(24-28wks)(CBC,ferritin,GCT/GTT,±group&screen25,Anyabnormalresultfromprior)

27-34weeks • Review2ndtrimesterlabresults• Reviewkickcounts26• Discussexpectations,fears,familyadjustment,violence

o OfferTdapfrom27-32weeks27o AdministerRhIgtoRh-vewomenat28wkso RepeatUSat30-32weeksifnecessary(previa,obstructingfibroid,etc.)28

34-37weeks • Reviewreasonstocometotriage• Discusscircumcision29

o FaxANrecordstoOBTriageo GBSswab(35-37wks)30o DiscontinueASAat36wkso Startantiviralsat36wksifHxofgenitalHSV31

37-40weeks • Reviewsignsoflabour32• Discusspainmanagement• Discussbreastfeeding

o ScheduleBPPstartingat38wksif≥40y/o

>40weeks • Discusspossibilityofinduction33 o ScheduleBPPq3-4dayso Bookinduction


ROUTINEPRENATALCHECKLISTRESOURCE1NutritionandWeightGainDuringthe1sttrimester,noextracaloriesarerequired,butcaloricneedsincreaseslightlyduringthe2ndand3rdtrimesters.Fluidneedsincreaseinpregnancyto10cups/dayduetoriseinvolumerequirements.AccordingtoCanada’sFoodGuide,adietduringpregnancyshouldcontain2200-2400kcal/day.Withobesitybecominganincreasinglyprevalentconcern,itiscriticaltoperformpre-pregnancyBMImeasurementsandoffercounselingregardingappropriateweightgain.Obesewomenshouldbeadvisedoftheincreasedriskofcomplicationsincludingcardiacdisease,pulmonarydisease,gestationalhypertension,gestationaldiabetes,andobstructivesleepapnea.Inaddition,theirfetusisatincreasedriskofcongenitalanomaliesandspontaneousabortion.ThesewomenarealsoatsignificantlyhigherriskofrequiringC-sections.Weightgaininpregnancybasedonpre-pregnancymaternalweight: Underweight(BMI<19) Average(BMI19-25) Overweight(BMI>25)28-40lbs 25-35lbs 15-25lbs12-18kg 11-16kg 7-12kg

SafeFoodsinPregnancy-previouslythoughttobeunsafe• Soft-ripenedcheeses,delimeats,andrefrigeratedreadytoeatfoods(includingcheesefromunpasteurized

milk)–associatedpathogenislisteriamonocytogenes.Riskislowiffoodishandledandstoredproperlyandmaythereforebeconsumedinmoderationifobtainedfromreputablesources

• Raworsoft-cookedeggs:associatedpathogenissalmonella.Raworundercookedeggsshouldbeavoidedunlesspasteurizedeggshavebeenusedinplaceofeggswithshells.Commercialproducts(asopposedtohome-made)containingraweggsi.e.mayonnaise,saladdressing,custards,andicecreamareallmadewithpasteurizedeggs

• Rawfishandshellfish:associatedpathogensarenoroviruses,vibrionaceae,salmonellaaswellassomehelminthicandprotozoanspecies.Shellfishaccountformoreinfectionsthanfinfish.Seafoodmarkedforhumanconsumptionisinspectedformicrobialcontamination.Whilecookingisthemosteffectivewayofinactivatingparasites,flashfreezingisalsoeffectiveandusedmostoftenonsushigradefish.Rawfishfromareputableplace,consumedsoonafterpurchaseissafe

• FishConsumptioninpregnancyo HealthCanadarecommendseatingatleast150grams(5ounces)ofcookedfisheachweekin

pregnancy,withpreferenceforLowContaminantFish(i.e.lowmercuryandhighfattyacids)§ Includesanchovy,capelin,char,hake,herring,Atlanticmackerel,mullet,Pollock,salmon,

smelt,rainbowtrout,lakewhitefish,bluecrab,shrimp,clam,mussel,andoystero Limit75gpermonth(approximately1/2cup)ofhighmercuryfish,whichincludesfresh/frozen

tuna,shark,swordfish,marlin,orangeroughy,andescolaro CannedTuna

§ CannedAlbacore(white)Tunashouldbelimitedto2.5canspermonth§ CannedLightTunashouldbelimitedto2.5cansperweek

2ExerciseInuncomplicatedpregnancies,womenshouldbeencouragedtoparticipateinaerobicandstrength-conditioningexercisesregardlessofpreviouslevelofphysicalactivity.Newevidencesuggestsbetterengagementinexerciseifbegunearlyorpriortopregnancy.Ifnotpreviouslystarted,exercisingshouldbere-emphasizedinthe2nd


trimesterwhensymptomssuchasnausea,vomiting,andfatiguediminishandpriortothephysicallimitationsofthe3rdtrimester.Recentevidence,focusingonbothaerobicandstrength-conditioningexerciseregimensinpregnancy,hasshownthatbenefitsofexerciseincludefewernewborncomplications,areducednumberofC-sectionsorinstrumentaldeliveries,andadecreasedincidenceofurinaryincontinence,excessiveweightgain,anddepression.Therehasbenoevidencetosuggestincreasesinearlypregnancyloss,latepregnancycomplications,abnormalfetalgrowth,oradverseneonataloutcomes.Theabsenceofexerciseisassociatedwithrisks,includinglossofmuscularandcardiovascularfitness,excessivematernalweightgain,higherriskofGDMorGHTN,developmentofvaricoseveinsandDVT,higherincidenceofphysicalcomplaintssuchasdyspneaorlowerbackpain,andpoorpsychologicaladjustmenttothephysicalchangesofpregnancy.

ThePhysicalActivityReadinessMedicalExaminationforPregnancy(PARmed-XforPregnancy)isanendorsedtoolforscreeningandguidingwomeninterestedinexercisingthroughpregnancy.WomenwhohavebeenexercisingpriortopregnancymaycontinuetheirexerciseregimenbasedonthePARmed-Xguidelines.Sedentarywomenshouldbeencouragedtostartwith15minutes3timesweeklyandgraduallyincreaseto30minutes4timesperweek.Thesafetyofexercisehasonlybeenevaluateduptomoderatelevelsofintensity.YoumayrefertoPARmedXforheartratetargetzones.Alternatively,advisewomentousethe“talktest,”forwhichtheyshouldbeabletomaintainaconversationduringexerciseandshouldreducetheintensityifthisisnotpossible.Womenshouldavoidexercisesthatcancauselossofbalance(i.e.horsebackriding,bikeriding,icehockey,etc.)aswellasscubadiving(fetusisnotprotectedfromdecompressionsickness/airembolism).Advisewomentostopexercisingandseekmedicaladviceiftheyexperienceanysymptomlistedbelow:

• Excessiveshortnessofbreath• Chestpain• Presyncope

• Vaginalbleeding• Painfulcontractions• Leakageofamnioticfluid

PleaserefertothePARmed-XforPregnancytoolforadditionalinformationat:http://www.csep.ca/en/publications/get-active-questionnaire

ContraindicationstoexerciseinpregnancyAbsoluteContraindications RelativeContraindications• Rupturedmembranes• Pretermlabour• Hypertensivedisordersofpregnancy• Incompetentcervix• Growthrestrictedfetus• Highordermultiplegestation(triplets)

• Placentapreviaafter28thweek• Persistent2ndor3rdtrimesterbleeding• Uncontrolledtype1diabetes,thyroiddisease,orotherseriouscardiovascular,respiratory,orsystemicdisorder

• Previousspontaneousabortion• Previouspretermbirth• Mild/moderatecardiovasculardisorder

• Mild/moderaterespiratorydisorder

• Anemia(Hb<100g/L)• Malnutritionoreatingdisorder• Twinpregnancyafter28thweek• Othersignificantmedicalcondition

ReprintedandmodifiedfromtheCanadianSocietyforExercisePhysiology


3Smoking,Alcohol,Cannabis,Drugs,andCaffeineAllwomenshouldbeappropriatelycounselledabouttherisksofpericonception,antepartum,andpostpartumsubstanceuse.Itiscriticaltoestablishrapportwithsubstance-usingwomenthroughanon-judgementalapproachandflexibilityinprovidingongoingprenatalcareandsupport.Smokingisassociatedwithspontaneousabortion,pretermlabour,prematureruptureofmembrane,placentaprevia,placentalabruption,intrauterinegrowthrestriction,andlowbirthweight.ItputstheneonateatincreasedriskofSIDSandperinatalmortality.Longtermeffectsonthechildincludechildhoodasthma,behaviouralproblems,andADHD.Psychosocialinterventionsareconsideredfirst-lineforquitting,followedbynicotinereplacementand/orpharmacotherapy.Alcoholconsumptionhasbeendirectlylinkedtofetalalcoholspectrumdisorder,whichincludesgrowthrestriction,facialdysmorphology,CNSdysfunction,andbraindamage.Theriskincreaseswithalcoholconsumption,butthereisnosafelevelformaternaldrinking.RecentevidencefromSwedenrevealedsubtlelongtermcognitiveandbehaviouraleffectsevenwithlow-dosealcoholconsumption.Cannabishashadinconsistenteffectsonpregnancybutmayhavelongtermcognitiveandbehaviouralconsequencesforexposedchildren.Risksofuseincludepretermlabour,lowbirthweight,lowerIQscores,andADHD.THCappearstobeinvolvedasitcrossestheplacentaintofetaltissueandcanaccumulateinbreastmilk.Otherdrugs,includingopioids,cocaine,andhallucinogensvaryintheireffectonthepregnancyandneonataloutcomes.Thereisstrongevidencesupportingopioidagonisttreatmentwithmethadoneorbuprenorphineforopioidusedisorders.Caffeinehasnotbeensubtantiatedasacauseofbirthdefects.Nonetheless,HealthCanadarecommendslimitingcaffeineto300mgofcaffeinedaily(approximately500mLdripcoffeeor1.2Lstrongtea).Increasedcaffeineconsumptionmaybeassociatedwithincreasedspontaneousabortionrates.Herbalteasmaybesafeinpregnancydependingoningredientsandamount(gingerbalm,orangepeel,rosehip,citruspeelandlindenflowerareconsideredsafe).4PrescriptionMedicationsAlmostanydrugthatexertsasystemiceffectinthemotherwillcrosstheplacentaandreachthefetus.Foranydrugusedinpregnancy,theadvantagesmustclearlyoutweightheriskstothefetus.Priortoconception,allmedicationsshouldbereviewedanddiscontinuationorsaferalternativesconsidered.Forinformationonsafetyofspecificmedicationsinpregnancy,seeDrugsinPregnancyandLactationorvisitMotheriskatwww.motherrisk.org.AllexpectantmothersshouldspeaktoaphysicianorpharmacistbeforetakingOTCmedications.5CongenitalAnomaliesandHereditaryDisordersScreeningfortheheterozygousorcarrierstateisrecommendedforindividualsbelongingtopopulationsknowntohaveanincreasedcarrierfrequencyforgeneticdisorders.Ifthereareconcernsforspecificgeneticdisorders,contactyourcommunity’sgeneticclinic.

1. Tay-Sachs(1in29AshkenaziJews,someFrenchCanadiansarecarriers.TestANYindividualwithevenamixedbackgroundinvolvingAshkenaziJewish)

• Autosomalrecessive,progressiveneurodegenerativedisorder,startsat3-6monthsofage


• Causedbydeficiencyofenzymehexosaminidase-A,whichbreaksdownafattywastesubstancefoundinbraincells,therebycausingtoxicaccumulationinthebrain

• Testingdetectsapproximately95%ofAshkenaziJewishcarriersand30%ofothercarriers• “Ashkenaziscreen”(includesTay-Sachs,Canavan,familialdysautonomia,Bloomsyndrome,

FanconiAnemiatypeC,MucolipidosistypeIV,NiemannPickdiseasetypeA&B)canbedonethroughHSC(patientscancall(416)813-5799tomakeappointment).

2. FamilialDysautonomia(1in30AshkenaziJewsarecarriers)• Autosomalrecessive,progressiveneurodegenerativedisorder• CausedbymutationintheIKBKAPgeneonchromosome9• Testingdetectsapproximately99%ofAshkenaziJewishcarriers

3. CanavanDisease(1in57AshkenaziJewsarecarriers)• Autosomalrecessive,progressiveneurodegenerativedisorder,startsat3-6monthsofage• Causedbydeficiencyofenzymeaspartoacylase,whichbreaksdownN-acetylasparticacidin

braintissue,therebycausingtoxicaccumulationinthebrain• Testingdetectsapproximately99%ofAshkenaziJewishcarriersand50-55%ofothercarriers

4. Other“Ashkenazipanel”diseases(inadditiontoabove3)• BloomSyndrome(1in102),FanconiAnemiaGroupC(1in89),MucolipidosisIV(1in100),

NiemannPickDiseasetypeA&B(1in90)5. Thalassemiaαandβ(prevalentinAsian,Black,Hispanic,Mediterranean,MiddleEastpeople)

• HbelectrophoresisifMCV<80• ↑HbA2orHbFlevelsindicativeofβ-thalassemiacarrierstate• PresenceofHbHinclusionbodiesinRBCsindicatesα-thalassemiacarrierstate(may

havenormalelectrophoresis)• ConsiderorderingHbelectrophoresiswithinitialbloodworkifsuspicious

6. SickleCellDisease(1in12Blacks,alsofoundinIndian,Mediterranean,Asian,MiddleEastern)• CheckforMCVandsicklecelltraitinbothparents

7. CysticFibrosis(1in20Caucasians)• RefertoGeneticsifanyfamilyhistory

6RubellaandVaricellaMaternalinfectionwithrubellauntil20weeksGAcancausecongenitalrubellasyndrome(cataracts,deafness,hepatosplenomegaly,congenitalheartdisease,mentalretardation,hematologicchanges,IUGR,anddeath).Allwomenofchildbearingageshouldhavetheirrubellaimmunitydetermined.Themajoritywillbeimmuneasaresultofchildhoodimmunization.Ifapregnantwomanlacksantibodies,sheshouldbeadvisedoftheriskandencouragedtoavoidexposureandimmunizepostpartum.Varicellainfectioninpregnancy,especiallyduringthefirsthalf,canleadtocongenitalvaricellasyndrome(lowbirthweight,skinscarring,ophthalmicabnormalities,limbhypoplasia,corticalatrophy,etc.).AllwomenwithoutadefinitehistoryofpriorchickenpoxorVaricellavaccineshouldbetestedforvaricellaimmunity.Ifapregnantwomanisnotimmune,sheshouldbeadvisedoftheriskandencouragedtoavoidexposure.Incaseofsignificantexposure,administrationofvaricella-zosterimmunoglobulin(VZIG)willusuallypreventinfectionifgivenwithin96hoursofexposure.Ifanon-pregnantwomanlacksantibodiestorubella,sheshouldbeimmunizedwiththeliveattenuatedvaccine(MMR)andadvisedtodeferpregnancyfor1monthafterwards(notethattherisktothefetusissmall,andaccidentalconceptionisnotanindicationfortermination).Ifanon-pregnantwomanlacksantibodiestovaricella,sheshouldbevaccinatedwithVarivax(2doses,4-8weeksapart)andadvisedtodeferpregnancyfor1monthafterthe2ndvaccination.


7HIVHIVistransmittedfromaninfectedmothertoherfetusin20-30%ofcasesviaverticalandperinataltransmission.Thetransmissionratecanbereducedto1-2%withmaternaluseofanti-retroviralsduringpregnancy.Therefore,HIVtestingshouldbeofferedtoallpregnantwomenandencouragedwhenriskfactorsarepresent.Womenwhoengageinhighriskbehaviourshouldbeofferedtestingeachtrimester.WomenwhotestpositiveshouldbereferredtoapractitionerexperiencedintreatingHIV-positivewomen.8FolicAcidSupplementationAllreproductive-agedwomenshouldbeadvisedaboutthebenefitsoffolicaidsupplementationwhetherornotpregnancyiscontemplatedduetothehighrateofunplannedpregnancy.Supplementationpriortoconceptionandinearlypregnancyhasbeenassociatedwithpreventionofneuraltubedefectsandothercongenitalanomalies,includingheartdefects,uterinetractanomalies,oralfacialclefts,limbdefects,andpyloricstenosis.Neuraltubedefects(NTDs)occurinCanadaatarateofapproximately1-2per1,000births.Folicacidreducestherecurrenceriskwith1previouslyaffectedchildfrom2-5%byover70%.InlowriskpregnanciesfolicacidreducesNTDsby50-70%.Supplementationshouldbegin2-3monthspriortoconceptionandcontinuethroughoutpregnancyandpostpartumperiod.Recommendeddailyfolicacidsupplementationvariesbasedonriskinthefirsttrimester,butallwomenshouldtake0.4-1mgfolicaciddailyafter12weeksgestationuntil6weekspostpartumorcompletionofbreastfeeding.Womenatlowriskshouldsupplement0.4mgdailythroughoutthepregnancy.Womenatmediumriskshouldsupplement1mgdailyuntil12weeks.Mediumriskincludes:

• PersonalorFHxoffolate-sensitivecongenitalanomalies• FamilyhistoryofNTDin1stor2nddegreerelative• Maternaldiabetes• Teratogenicmedicationswithsecondaryfetalteratogeniceffectsbyfolateinhibition(ex:anticonvulsants)• MaternalGImalabsorptionconditions(ex:Crohn’s,Celiac,gastricbypass,dialysis)

Womenathighriskshouldsupplement4mgdailyuntil12weeks.Highriskincludes:

• WomenormalepartnerwithpersonalNTD• Historyorapreviousneuraltubepregnancy

Risksoffolicacidsupplementationareminimal,butinclude:• Allergicreaction(rare)–erythema,rash,pruritus,generalmalaise,bronchospasm• Seizuredisorders–convulsionsmayoccurinpreviouslycontrolledpatients• Neoplasia–possibleassociationwithneoplasiaorexacerbationofpre-existingcolorectalcancer9MaternalAge≥40Ageover40confersadditionalriskofcomplications,including:

• Spontaneousabortion• Placentaprevia• Gestationaldiabetesmellitus• Pre-eclampsia

• C-section• Pretermdelivery• IUGR/lowbirthweight• Stillbirth

• Congenitalanomalies–anyaneuploidy,butespeciallyanadditionalXchromosomeortrisomy13,18,21


WomeninthisagegrouphaveaccesstoNIPTcoveredbyOHIP.Amniocentesisshouldnotbeofferedonthebasisofagealone.Anotherspecialmanagementconsiderationsisinductionby40weeks,aswomeninthisagegroupareconsideredbiologicallypost-termat39weeks.

10PrenatalScreeningOverall,97%ofbabiesarebornhealthy.Theremainingarebornwithsometypeofabnormalities,rangingfromminortomajor.Increasingmaternalageconfersadditionalrisk,butisnotthesolecontributor.Assuch,prenatalgeneticscreeningshouldbeofferedtoallpregnantwomen,regardlessofage.MultiplescreeningoptionsareavailableinCanadaandvarybasedongeographiclimitations.InToronto,themostcommonscreeningtestsincludeeFTS,MSS,NIPT,amniocentesis,andCVS. eFTS NIPT MSSTestComponents Bloodtest+NTultrasound Bloodtestforcell-freeDNA BloodtestGAforTesting 11-13+6weeksGA 9-10weeksGAonwards 15-20+6weeksGADetectionRate 85-90% 99% 80%FalsePositiveRate Appx.3-6% Under0.1% Appx.5%ReprintedandmodifiedfromGeneticsEducationCanada–KnowledgeOrganization

Enhancedfirsttrimesterscreening(eFTS)canbeofferedasanalternativetoIPSparticularlyforwomenwhowouldlikeanearlierresult(at14weeks)andhenceanearlieramniocentesisorCVS.ItisacombinedbloodtestandNTscandonebetween11-13+6weeks.ItisavailablethroughNYGHandMountSinaiHospital.Asthetestdoesnotincludea2ndtrimesterAFP,itdoesnotscreenforONTDs.TheSOGCconsidersananatomicUSat18-20weeksasanappropriatealternativeforONTDscreening.Maternalserumscreening(MSS)shouldbeofferedtoallpregnantwomenwhopresenttoolateforFTS(≥14weeks).Itisavailablebetween15-20+6weeksandinvolvesmaternalserumtestingofAFP,hCG,uE3andDIA.Non-InvasivePrenatalTesting(NIPT)usesfetalDNAcirculatinginthematernalcirculationtoscreenforaneuploidy.Itoffersa99%detectionratewitha0.1%falsepositiverateforTrisomy21,>97%detectionrateforTrisomy18,and>93%detectionrateforTrisomy13.Thefalsepositiverateis<0.1%.Positiveresultsarereportedaseitherpositive,negative,orsuspected.Thetesthasbeenvalidatedinbothhighandlowriskpopulations.OHIPcoversNIPTforhigh-riskpopulations,includingwomen≥40,thosewithpreviouslyaffectedfetuswithTrisomy21,andpositiveIPS/FTSincurrentpregnancy.Allwomen,however,shouldbeofferedthetestandcanpayoutofpocketforit.Thebasecostisapproximately$500,butadditionaltestsfordeletionsyndromesareavailableforadditionalcost(includingDiGeorgesyndrome,Angelmansyndrome,Cri-du-chatsyndrome,Prader-Willisyndrome,and1p36deletionsyndrome).Forthetesttobesuccessful,asufficientfractionoffetalDNAmustbeextractedfromthematernalcirculation.Theoverallprobabilityofanon-interpretableresultrangesfrom1-8%.MaternalfactorsthatreducethefetalfractionofDNAincludeobesityandearlygestationalage(priorto10-11weeks).Womenwithinconclusiveresultsshouldbeofferedaredrawwitha50-60%likelihoodofasuccessfultest,butretestingmustbebalancedwithsignificantlydelayeddiagnosis.Additionally,unsuccessfultestsduetolowfetalfractionareinthemselvesassociatedwithupto5%riskofaneuploidy;accordingly,thesewomenshouldbeofferedanultrasoundandgeneticcounselingtodiscussinvasivefetalchromosomeinvestigations.Currently,multiplecompaniesinOntarioofferprivateNIPTtesting.Moreinformationcanbefoundat:

• Panorama®viaLifeLabsathttps://www.lifelabsgenetics.com/product/non-invasive-prenatal-testing/• Harmony®viaDynacareathttps://www.dynacare.ca/news/harmony-prenatal-test-(nipt).aspx


WomenundergoingNIPTshouldstillundergoanuchaltranslucencyultrasound.AlthoughtheNIPTalreadyscreensforaneuploidy,alargeNTcanindicateotherstructuralproblems,includingcardiacanomalies.Invasiveprenatalproceduresforcytogeneticanalysisshouldbeofferedwithapositive/suspectedNIPTresult.Itshouldrarelybeofferedpriortonon-invasivescreeningforaneuploidy.Itmaybeofferedifwomenareatincreasedriskoffetalaneuploidydueto(1)ultrasoundfindings,(2)pregnancywasconceivedbyinvitrofertilizationwithintracytoplasmicsperminjection,or(3)thewomanorherpartnerhasahistoryofapreviouschildorfetuswithchromosomalabnormalityorisacarrierofachromosomerearrangementthatincreasestheriskofhavingafetuswithachromosomalabnormality.AmniocentesisisaprocedureinwhichamnioticfluidisextractedbyUSguidedneedleaspiration.Itcanbedoneanytimeafter15weeksandcarriesanadditionalriskofmiscarriageof0.01-0.5%(baselineriskofspontaneousabortioninearly2ndtrimesteris3%).Itcanbearrangedat:NYGHPrenatalDiagnosisProgram Phone:(416)756-6345SunnybrookHighRiskObstetricsProgram Phone:(416)480-5367ChorionicVillusSampling(CVS)isaprocedureinwhichasampleofplacentaisobtainedforanalysis.Itcanbedoneasearlyas10weeksandcarriesanadditionalriskofmiscarriageof1%.Confinedplacentalmosaicism,thoughrare,maylimitthevalidityofthetestresults.Itcanbearrangedat:MSHPrenatalDiagnosisProgram Phone:(416)586-4523SunnybrookHighRiskObstetricsProgram Phone:(416)480-5367BothCVSandaminocentesisarenowbeingprocessedbymicroarrayratherthankaryotyping.Chromosomemicroarrayanalysisprovideshigherresolutionofdetection,anditisabletodetectduplicationsanddeletionsat1.5to3.5mbrange,ratherthanlargerscalechanges.Additionallyturnaroundtimeisusually<2weeksincomparisonto2-3weekswithkaryotyping.FISHanalysisforpositiveeFTSresultsisavailabletolookfortrisomieswithresultsavailablewithin48hours.Microarraytestingcanpotentiallyleadtodiagnosisofadditionsanddeletionsofunknownsignificance,whichpresentsachallengingethicalissueandmaycauseanxietyforparents.Inamultiplegestationpregnancy,fetalnuchaltranslucencyincombinationwithmaternalageisanacceptablefirsttrimesterscreenforaneuploidy.However,NIPTcanbeoffered,asitprovidesimprovementovernuchaltranslucencyandagealone,butitisonlycoveredbyOHIPifmeetscriteria.Referraltoaplacentaclinicorconsiderationofdedicatedplacentalultrasound:Followingafetalultrasound,patientscanbereferredforconsultationandadedicatedplacentalultrasoundtolookatimplantation,vessels,andbloodflow.Criteriaforreferralvarybyclinicandshouldbeconfirmedpriortoreferral.Areferralshouldbeconsideredif:IntrapartumConsultation

1. AbnormalFTS/MSS/IPStestingresults–confirmthresholdswithclinicpriortoreferral.Thereferralshouldincludetheanatomyscan,geneticcounselinginformation,andamniocentesisresults.

2. Backgroundmedicalriskfactorsforplacentaldamage,includinginsulin-dependentdiabetes,significantobesity(BMI>35),advancedmaternalage(>40),chronichypertension,previousvenousthromboembolism,renaldisease,orautoimmunedisease

3. Previouscomplexobstetricalhistorysuggestingplacentaldamage.Theseincludepriorunexplained/placentalloss>16weeks,stillbirth>20weeks,delivery<34weeksduetohypertension/preeclampsia/HELLPsyndrome,orintrauterinegrowthrestriction(IUGR)duetoplacentaldisease


4. Suspectedinvasiveplacenta(placentaaccreta/percreta)–shouldbesuspiciousifhaveanteriorloworpreviaidentifiedinapatientwithpreviousCaesareandeliveries,myomectomy,multipleD&C’s,otheruterinesurgeries

5. CurrentpregnancycomplicatedbyhypertensionorIUGR6. Sonographicabnormalitiesoftheplacentaand/ormembranes7. Placental/chorionicity/growthproblemsinmulti-fetalpregnancies

Pre-PregnancyConsultation

1. Multipleriskfactorsforplacentalinsufficiency2. Previouspregnancycomplicatedbystillbirth/severepreeclampsia,HELLPsyndrome,IUGRdueto

placentalinsufficiency3. Highriskforinvasiveplacenta(≥3priorC-sectionsormultipleotherriskfactors)

Giventhelongwaittimestotheplacentaclinic(upto4months),referralsforpre-pregnancyconsultationmaybedivertedtopre-pregnancycounsellingclinics.11RiskofInfectionsInfluenzaisnotteratogenicbutconfersanincreasedriskofhospitalizationandseriouscomplicationsinpregnancy.Allwomenwithsuspectedordocumentedinfluenzainfection,regardlessofimmunizationhistory,shouldbetreatedwithoseltamivir75mgpobidx5days.Toxoplasmosisisaprotozoalinfectiontransmittedprimarilybyeatingrawmeatorthroughcontactwithcatfeces.Approximately30%ofwomenacquireprotectiveanti-toxoplasmaIgGantibody(serumtestavailable)beforepregnancy,therebypreventingtransmissiontothefetus.Asthesymptomsofacuteinfectionarenon-specificinfluenza-like,identificationandsubsequenttreatmentarechallenging.Lessthan10%ofnewbornswithcongenitaltoxoplasmosishavesignsatbirth(↓BW,hepatosplenomegaly,icterus,anemia,CNSproblems,chorioretinaldisease).Pregnantwomenshouldbeadvisedtoavoidcontactwithcatfecesoreatingrawmeat.HumanparvovirusB19iscommonlyassociatedwith“fifthdisease”orerythemainfectiosuminchildhood.Infectionanytimeduringpregnancymayresultinspontaneousabortion,fetalanemia,cardiacfailure,non-immunehydrops,orfetaldeath(9%).Approximately60%ofadultsareimmune.Daycareworkersandteachersareparticularlyatriskofexposure.Pregnantwomenexposedtoparvovirus,regardlessofgestation,needtohavetheirimmunityestablished.Cytomegalovirus(CMV)isthemostcommoncongenitalviralinfection,affecting0.3-14per1,000livebirths.Daycarecentresareacommonsourceofinfection,andmaternalimmunity(50-80%)doesnotpreventrecurrenceorcongenitalinfection.Mostmaternalinfectionsareasymptomatic,but15%haveamono-likesyndrome.Affectedinfantsmayhave↓BW,hepatosplenomegaly,hemolyticanemia,andavarietyofneurologiccomplications.HerpesSimplexVirus(HSV)genitalinfectionshaveincreasedprevalanceinCanada.NeonatalHSVreferstotheperipartumacquisitionofthevirusfromthematernalgenitaltract.CongenitalHSVinfectionisdistinctfromneonatalHSVreferringtotheacquisitionofHSVinutero.Themanifestationsofdiseaseareclassifiedintothreelevelsofdisease:

• Skin,eye,andmouthinfection• Centralnervoussystemdisease(encephalitis)• Disseminateddisease(90%mortalityifuntreated)

Congentialdiseasemayalsobemanifestedbymicrocephaly,hepatosplenomegaly,IUGR,andintra-uterinefetaldemise.


Womenshouldbecounselledonincreasedriskofspontaneousabortion,IUGR,andprematurelabourwithaprimaryinfection.Theriskoftransferringthevirusis2-5%withclinically-apparentlesionsattimeofdelivery,thoughasymptomaticsheddingisunpredictableandposesatransferriskof0.02-0.05%.WomenwithknowndiseaseshouldundergoHSVprophylaxis,whichisdiscussedlaterinthisdocument.12NauseaandVomitingofPregnancyNauseaandvomitingofpregnancy(NVP)affectsupto80%ofwomenandcansignificantlyimpactqualityoflife.Itistypicallymostsevereinthe1sttrimester.HyperemesisgravidumisanextremeformofNVPandaffectsupto2%ofpregnancies.Itcarriesriskoflowbirthweight,pretermlabour,SGA,andlowerAPGARscores.Non-pharmacologicalmanagementislistedbelow(evidencegradeislistedinparentheses):

1. Dietarychanges(gradeIII)–separatingsolidsandliquids;eatingsmall,frequentmealsofblandfoods;avoidingfattyfoods;avoidingdrinkingcold,tart,orsweetbeverages;avoidingsensorystimulisuchasstrongodours• Advisewomentoeatwhateverpregnancy-safefood

appealstothem2. Discontinuingironsupplementation(gradeII)–iron

requirementsdonotriseuntil2ndtrimester• Advisesubstitutingiron-containingprenatalvitaminswith

folicacidorvitaminslowiniron3. Increasingrest(gradeIII)–fatiguecanexacerbateNVPand

sleeprequirementsincreaseinearlypregnancy• Recommendincreasedrestandleave-of-absencefrom

work(withultimategoalofshorteningnumberofdayslostfromwork)

4. Ginger(gradeI)–improvesgastricmotilitythroughdopamineandserotoninantagonism(250mgpoqid)

5. P6acupressure(gradeI)–applypressuretoP6acupoint(3fingerbreadthsproximaltowristbetweentendonsofpalmarislongusandflexorcarpiradialismuscles).Acupressurewristbandsareavailable,offeringaconvenientmethodtoapplyconsistentpressuretothearea.

6. Psychotherapy(gradeI)–mindfulness-basedcognitivetherapymaybebeneficialasanadjunct

PharmacologicaltherapyshouldbeofferedassoonaspossibleafterthediagnosisofNVPandincludes:

• Diclectin®(10mgdoxylaminesuccinateand10mgpyridoxineHClcombined)isadelayed-releasecombinationofvitaminB6andH1receptorantagonist,whichtypicallytakeseffect4-6hoursafterintake

o Classicallyprescribedas2tabsPOqhs(topreventmorningnausea),1tabqAM,1tabqPM(dailymax:8tabs)

• Dimenhydrinate50mgq4-6hPO/PR• Metoclopramide5-10mgq8hPO/IM• Chlorpromazine10-25mgq4-6hPOor25-50mgq4hIM• Prochlorperazine5-10mgq6-8hPO/PR/IM• Promethazine12.5-25mgq4-6hPO/IM• Lastline:ondansetron8mgq12hor4mgq8hPO

ReprintedandmodifiedfromtheSocietyofObstetricsandGynecologyofCanada


o Safetyofondansetroniscontroversial–maybeassociatedwithincreasedriskofbirthdefects,particularlycleftpalateandcardiacanomalies.MustbebalancedagainstrisksofNVP.

ThefollowingalgorithmisofferedbytheSOGCforthemanagementofnauseaandvomitinginpregnancy:



Whennauseaandvomitingisrefractorytoinitialpharmacotherapy,proceedwithinvestigationforotherpotentialcausesorexacerbatingfactors,includingGI,GU,CNS,andtoxic/metabolicproblems.Investigationmayincludeelectrolytes,TSH,creatinine,LFTs,druglevels,ultrasound,andH.pyloritesting.13LowDoseASALowdoseASAisusedasaprophylactictreatmentforpatientsatriskforpreeclampsiaandIUGR.IthasbeenshowntoreducetheriskofpreeclampsiaandIUGRby50%.WomenwiththefollowingindicationsshouldbeginASA81mgpodailyat12-16weeksuntil36weeks:

• Previoushistoryofplacentalinsufficiencysyndromes(ex:IUGR,preeclampsia)• Certaininflammatoryconditions,includingantiphospholipidsyndrome• Womenwith2ormoreofthefollowingriskfactors:

o Pregestationalhypertensiono Obesityo Maternalage>40o Useofartificialreproductivetechnologyincurrentpregnancyo Pregestationaldiabeteso Multiplegestationo Previoushistoryofplacentalabruptionorinfarction

TheriskforpreeclampsiacanbecalculatedusingthevalidatedPreeclampsiaRiskCalculator,availableat:https://fetalmedicine.org/research/assess/preeclampsia14DatingUltrasoundTheSOGCGuidelineonDeterminationofGestationalAge(2014)recommendsdatingultrasoundsinfirsttrimesterevenwithcertainLMPdates.AsmostpatientsundergoanNTscanat11-13+6weeks,thisscanmaybeusedfordatingaswell.Ultrasoundinthefirstandsecondtrimesters(≤23weeks)ismoreaccuratethana“certain”menstrualdatefordetermininggestationageinspontaneousconceptionsandisthebestmethodforestimatingthedeliverydate.Assuch,datingshouldfollowultrasoundresultsoncetheybecomeavailable.Therehavebeennoprovenadversebiologicaleffectsassociatedwithobstetricalultrasound.Thepotentialadverseeffectoftissueheatingfromenergyabsorptionoftheultrasoundbeamismanagedbyroutinetechniquesthatmaintainasufficientlylowthermalindexlevel.15FirstTrimesterBloodworkFerritinshouldbemeasuredin1sttrimesterandagainat24-28weeks.Asubstantialproportionofwomeninpregnancyareirondeficientwithouthavingmicrocyticanemia.Replacingirondecreasesriskoftransfusionperipartumandtheassociated8%riskofalloimmunizationwitheachtransfusedunit.Irondeficiencyinpregnancyisdefinedasferritin<70.Anyoralironsupplementiseffective.Ifthepatientcannottolerateoraliron,patientswithferritin<50andHb<105shouldreceiveIVVenofer.TSHshouldbemeasuredin1sttrimesterwithrepeattestingifabnormalorsymptomatic.NormalTSHrangeinpregnancydropsto0.1-4.0asß-hCGmimicsTSHontitres.Untreatedmaternalhypothyroidismincreasescomplicationsincludingprematurebirth,lowbirthweight,pregnancyloss,andloweroffspringIQ.

• TSH>4.0=hypothyroidism,andshouldalwaysbetreated• TSH2.5-4.0=sublinicalhypothyroidismandshouldbetreatedonlyifanti-TPOABpositive.Accordingly,

subsequentanti-TPOABtestingshouldbeperformedtoguidetreatmentdecision.• Treatmentmainstayislevothyroxine,targettingTSHbetween0.1-2.5


o Adoseofonly25-50mcgistypicallysufficientforeffectiveofmildhypothyroidism• HypothyroidwomenshouldhavetheirTSHmonitoredq4wuntilmidgestationandatleastoncenear30

weeksgestation• Euthyroidwomenwhoareknowntobeanti-TPOABoranti-TgABpositiveshouldhaveTSHtestedattime

ofpregnancyandq4wuntilmidgestation• Non-pregnantwomenwithhypothyroidismshouldincreasetheirlevothyroxineby20-30%immediatelyif

suspectedorconfirmedpregnant(canbeaccomplishedbytakingtwoadditionaltabletsweeklyinadditiontocurrentdailylevothyroxinedosage)

• HyperthyroidismshouldbeconfirmedwithT4andT3,asß-hCGsuppressesTSHlevels.Iftruehyperthyroidism,proceedwithantibodytestingandreferralformanagement.

HbelectrophoresisshouldbeorderedonpatientswithMCV<80orifBlack,Indian,Mediterranean,Asian,orMiddleEastern.Syphilis,causedbyTreponemapallidum,cancrosstheplacentaandcausecongenitalsyphilis(hepatosplenomegaly,osteochondritis,CNSproblems),stillbirth,orneonataldeath.HepatitisBsurfaceantibodyshouldbetestedinallpregnantwomen.Ifpositive,proceedwithfurthertesting

includingHBeAg,HBVDNA,ALT,andultrasound.NeonatesborntopositivemothersshouldbevaccinatedforhepatitisBandgivenhepatitisBimmunoglobulinwithinthefirst12hoursoflife.Repeatdosesofvaccinearegivenatboth1and6monthsofage.16Gonorrhea,Chlamydia,andAsymptomaticBacteriuriaGonorrheahasbeenassociatedwithincreasedriskofPROM,intra-amnioticinfection,perinatalmortality,andneonatalconjunctivitis.Itshouldbetreatedwithazithromycin1gpox1inadditiontoceftriaxone250mgIMx1orcefixime800mgpox1.Ifpositiveduringpregnancy,performatestofcureandrepeattestinginthe3rdtrimester.Chlamydiacanbetramsmitedtotheneonateduringbirth.Ifpositive,itshouldbetreatedwithazithromycin1gpox1oramoxicillin500mgpotidx7days.Ifpositiveduringpregnancy,performatestofcureandrepeattestinginthe3rdtrimester.Asymptomaticbacteriuriainpregnancyhasbeenassociatedwithincreasedriskofpyelonephritis,lowbirthweight,andpretermbirth.Antibiotictreatmenthasbeenshowntoreducetherisksofpyelonephritisandlowbirthweight,butnotpretermbirth.Allpositivecultureswith>100,000CFU/mLshouldbetreatedwithappropriateantibiotics.AllwomenwithGBSbacteriuriainthecurrentpregnancyareconsideredcolonizedatthetimeoflabourandshouldreceiveprophylacticantibiotics.17PregestationalorEarlyGestationalDiabetesMellitusTheincidenceofgestationalandpregestationaldiabetes(GDMandPGDM)hasbeenrisingoverthepasttwodecades.WomenwithGDMareatincreasedriskofmaternal,peripartum,andneonatalcomplications,includingshoulderdystocia,C-section,largeforgestationalage,prematurity,Erb’spalsy,andmajormalformations.Universalscreeningoccursat24-28weeksandwillbediscussedlaterinthisdocument.InwomenathighriskofGDMbasedonmultipleriskfactors,earlierscreeninginthe1sttrimestershouldtakeplace.Riskfactorsinclude:

• PreviousdiagnosisofGDM• Prediabetes• Memberofahigh-riskpopulation(Aboriginal,Hispanic,SouthAsian,Asian,African)


• Age>35• BMI>30kg/m2• PCOS• Acanthosisnigricans• Corticosteroiduse• Historyofmacrosomicinfant• Currentfetalmacrosomiaorpolyhydramnios

Inthe2018guidelines,theCanadianDiabetesAssociationmakesthefollowingrecommendationfortestingglucoselevelsinearlypregnancy:

• A1cshouldbetestedwiththefirsttrimesterbloodworkinpregnantwomenwithanyriskfactoro Ifthepatienthasanemiaorhemoglobinopathy,aFPGshouldbedoneinstead

• Cutoffsfordiagnosisofdiabetesremainunchanged:FPG≥7.1orA1c≥6.5%• AllwomendiagnosedwithGDMshouldbereferredtoamulti-disciplinarydiabetespregnancyprogram,if

available• AFPGof5.1-7.0orA1cof5.7-6.4%confersignificantriskofGDMlaterinpregnancyandshouldprompt

referraltoadietician o Consultyourlocalhospitalregardingavailableresources

§ SunnybrookoffersdieticiansthroughW&BDiabetesinPregnancyClinic WomenwithGDMshouldalsobescreenedforT2DMwitha75gOGTTbetween6weeksand6monthspostpartum.18FluVaccineTheinactivatedinfluenzavaccineshouldbeofferedtoallpregnantwomenduringtheinfluenzaseason.Itoffersprotectiontothepatientandreducesproveninfluenzainfectionsininfantsunder6monthsofagebyover60%.Noteonothervaccines:toxoidsandinactivatedviralandbacterialvaccinescanbesafelyusedinpregnancyandwhilebreastfeeding.Livevaccines(ex:MMR,Varicella)shouldnotbeadministeredduringpregnancyduetotheoreticalrisktothefetus.Ifitisinadvertentlygivenduringpregnancy,womenshouldnotbecounselledtoterminatethepregnancyduetoteratogenicrisk.Thesevaccinesmaybegiventobreastfeedingwomen.19TrialofLabourafterC-sectionThesuccessrateoftrialoflabourafterC-section(TOLAC)isapproximately75%.PredictorsofsuccessfulvaginalbirthafterC-sectionincludepreviousvaginaldeliveryandnon-recurringindicationforCaesareanbirth,suchasmalpresentationorgestationalhypertension.AhistoryofCaesareanbirthfordystocia,failuretoprogress,orcephalopelvicdisproportionhasbeeninconsistentlyassociatedwithlowersuccessrates.Goodcandidatesincludewomenwithonepreviouslowtransverseuterineincision.Risksshouldbediscussedreviewed,andinclude:

• Maternalrisks–uterinerupture(0.5%),perinatalmortality(0.13%)• Babyrisks–hypoxicischemicencephalopathy,hemorrhage,death

Contraindicationsinclude:

• Verticalincision• >1C-section• High-riskuterinescars,includingfromprioruterinerupture


• PastC-sectionwithin18months• Placentaprevia,breech,etc.• Lackofappropriatefacility(ORmustbereadilyavailable)

20BacterialVaginosisBacterialvaginosis(BV)isthemostcommonlowergenitaltractdisorderinreproductive-agedwomen.Itisassociatedwithmultipleobstetricalcomplications,includingpretermlabour,pretermruptureofmembranes,spontaneousabortion,intra-amnioticinfection,postpartumendometritis,post-surgicalwoundinfections,andsubclinicalpelvicinflammatorydisease.ThereiscurrentlynoconsensusastowhethertoscreenortreatBVinallpregnantwomen.Guidelinescurrentlyrecommendscreeninghighriskwomenat12-16weeksaswellastestingsymptomaticwomen.Highriskwomenincludethosewithhistoryofpretermlabourorlowbirthweight.Ifpositive,patientsshouldbetreatedwithmetronidazole500mgpobidx7daysorclindamycin300mgpobidx7days.Topicalagentsarenotrecommendeddespitesimilarcurerates,astheyhavenotbeenshowntoeffectivelypreventpretermbirth.Testofcureshouldbedoneonemonthaftertreatment.21IndicationstoContactMD

AllpatientsareprovidedwithalistofredflagsymptomsthatshouldbereportedimmediatelytoanMD.Itisprudenttoreviewthefollowingsymptomswithpatients:• Vaginalbleeding• Leakingoffluidfromvagina• Markedchangeinfetalmovements• Abdominalpain • Persistentvomiting

• Chillsorfever• Dysuria• Dimnessorblurringofvision• Severeorcontinuousheadache• Swellingoffaceorfingers

22AnatomyUltrasoundTheanatomicalultrasoundisperformedbetween18and22weeks.Forobesewomen,theanatomyultrasoundshouldbescheduledat20to22weeks.Itisusedtoconfirmthenumberoffetuses,identifylocationofplacenta,screenmaternalorgans,anddetectcongenitalanomaliesandsoftmarkersofaneuploidy.Duedatesshouldnotbeadjustediftheyhavebeenestablishedbyanearlierultrasound.Anatomicalultrasoundreportsshouldincludepatientdemographicinformation,numberoffetuses,indicationsoflife,biometry,fetalanatomy,amnioticfluidamount,descriptionofplacenta,andreviewofmaternalanatomy.Whileasummaryoffindingsandrecommendationsforfurtherinvestigationsshouldbeincluded,itisimportanttoreviewtheresultsandensurenofindingsrequirefurtherfollowup.Tointerpretabnormalresults,pleaserefertothe2005SOGCguidelineentitled“FetalSoftMarkersinObstetricalUltrasound.”23CordBloodProgramsSeveralCordBloodProgramsofferprocessingandcryopreservationofstemcellsaftercollectionofumbilicalcordbloodatthetimeofdelivery.Frozenstemcellsmaybeusedinthefuturetotreatsomechildhoodcancersandotherpotentiallyfataldiseases(ex:lymphomaandleukemia).Itdoesnotcarrysignificantriskstomotherorbaby.Thereiscurrentlynoconsensusregardingprivatecordbloodcollectionanditremainsanoptionalservice.Patientsshouldbeadvisedthatcertainperipartumconsiderationsmayprecludecordbloodcollection.


Availableservicesinclude:• Privatestorage-servicecostsmoney,butcellsarekeptfordonor/familyuseonly.Thepatientwillbe

giventhecordbloodkittotaketothehospitalwiththemwhentheydeliver.Theapproximatecostis$975-$1175forthefirstyear,and$125peryearthereafter.Companiesinclude:

1. InsceptionBiosciences (905)206-2790 www.insception.com2. Progenics (416)221-1666 www.progenicscryobank.com3. CellsforLife (877)235-1997 www.cellsforlife.com4. CReATe (416)813-4700 www.createcordbank.com5. CordBloodBankofCanada (905)943-4933 www.cordbloodbankofcanada.com6. Healthcord (877)714-6361 www.healthcord.com

• Publiccordbloodbank–nocharge,butparentshavenorightstobankedsample.Therearespecificsituationsinwhichasamplemayberedirectedtothefamily(ex:needforasibling):

1. VictoriaAngel (905)471-1113 www.cellsforlife.com/victoriaangel/24PreventionofRhAlloimmunizationRhalloimmunizationbyimmunoprophylaxishasledtoamarkedreductioninperinataldeathbyerythroblastosisfetalis.Anti-Dimmunoglobulin(RhIg)shouldbeadministeredtoallRh–vewomenat28weeksandagainwithin72hoursofdelivery.Twoexceptionsexist:

• Womenwhohavepre-existinganti-Dantibodies.• FatherisknownandconfirmedtobeRh–ve.

ThestandarddoseofRhIgis300µg.Additionaldosesarerequiredforfetal-maternalhemorrhagegreaterthan30mL.Causesoflargerhemorrhageincludeplacentalabruption,placentapreviawithbleeding,blunttraumatoabdomen,andexternalcephalicversion.TodeterminetheexactamountofhemorrhageandtheamountofadditionalRhIgneeded,aBetke-Kleihaueracidelutiontestshouldbeperformed.Somefacilitieswillofferflowcytometrytesting,whichhasbettersensitivityandspecificity.OtherindicationsforRhIginRh–vewomenincludeabortion,ectopicpregnancy,partialmolarpregnancy,chorionicvillussampling,amniocentesis,andantepartumbleeding.

25GestationalDiabetesMellitusAsdiscussedabove,GDMconferssignificantrisktomotherandbaby.Allpregnantwomenshouldbescreenedbetween24-28weeks.Thepreferredscreeningmethodinvolvesa50gglucosechallengetest(GCT),inwhichanon-fastingpatientdrinksastandardizedsugarbeverageandundergoesasinglebloodtest1hourlater.Foranequivocalresult(7.8-11mmol/L),a75goralglucosetolerancetest(OGTT)isperfomed.Glucoselevelsaremeasuredfastingandat1hourand2hoursafterconsumingthesugarbeverage.Any1valueabovethethresholdisdiagnosticforGDM.Seealgorithmforadditionalinformation:


AnalternativeapproachisscreeningwithasingleOGTT(withouttheprecedingGCT).PleasenotethatthediagnosticcutoffsforOGTTdifferfromthe2-stepapproach.AllwomendiagnosedwithGDMshouldbereferredtoamulti-disciplinarydiabetesinpregnancyprogram,ifavailable.Ongoingsurveillanceinvolvesfrequentself-monitoringofbloodglucose,bothfastingandpostprandial.Glucosetargetsare:

• Fastingbloodsugars<5.3• 1hourpost-prandial<7.8• 2hourspost-prandial<6.7

FetalsurveillanceforwomenwithconfirmedGDMshouldcommenceat28weekswithabaselinesonographicassessmentoffetalgrowthandamnioticfluidvolume.Subsequentassessmentsshouldtakeplaceevery2-4weeks.At36weeks,medicallymanagedwomenwithGDMshouldundergoweeklyfetalwell-beingassessments(NSTorBPP)untildelivery.Itisalsoappropriatetomonitordiet-controlledpatients.PregnantwomenwithGDMorPGDMshouldbeofferedinductionbetween38-40weeks,dependingonglycemiccontrolandothercomorbidities.Intrapartumglucosemonitoringshouldcontinueevery2hours,targetingplasmalevelsof4-7mmol/L.AllwomenwithGDMshouldbescreenedforT2DMwitha75gOGTTbetween6weeksand6monthspostpartum.

26KickcountsLowriskwomenshouldbetaughthowtokickcount,shouldtheyperceiveadecreaseinfetalmovements.Kickcountsinvolveslyingstillfor2hourswithcoldjuiceandwithoutexternalstimulation.Womenshouldperceive6movementsin2hoursandcanstopassoonastheycount6.Iftheyhavelessthan6distinctmovementsin2hours,theyshouldbeassessedintriagewithanNSTandundergoaBPPwithin24hours.

ReprintedandmodifiedfromtheCanadianDiabetesAssociation(2018)


27TdapVaccineThetetanus,diptheria,andacellularpertusisvaccine(Adacel)shouldbeofferedtoallpregnantwomenideallybetween27-32weeksduringeverypregnancy,regardlessofvaccinationhistory.Thevaccineincreasestransplacentalpassageofpertussisantibodies,whichconfersadditionalimmunitytoinfantsuntiltheyreceivetheir2monthvaccines.28RepeatUltrasoundAt18weeksapproximately5%ofwomenhavelow-lyingplacentaonultrasound,but<0.5%haveplacentapreviaatterm.Repeatultrasoundin3rdtrimesterisnecessarytoensureplacentahasmigratedandisnolongerprevia.Aplacenta>2.0cmawayfromtheosisconsideredsafeforvaginaldelivery,thoughshorterdistancesmaybeconsideredwithOBGYNconsultationandanappropriatereviewofriskstothemomandnewborn.

29CircumcisionThe2015CanadianPediatricSocietyguidelineoncircumcisiondoesnotrecommendroutinecircumcisionforeverymalenewborn.Instead,itrecommendseachfamilyreceivecounsellingsothattheparentscanweightherisksandbenefitsinthecontextoftheirownfamilial,religious,andculturalbeliefs.Parentswhochoosetohavetheirsonscircumcisedshouldbereferredearlyintheneonatalperiodtoanexperiencedpractitioner.AscircumcisionsarenolongercoveredbyOHIP,theparentswillberequiredtopayapproximately$300-400fortheprocedure.

PotentialRisksandBenefitsofNeonatalCircumcisionPotentialBenefit PotentialRisk

Outcome EffectSize Outcome EffectSizePreventionofphimosis NNT=67 Minorbleeding 1.5%DecreaseinearlyUTI NNT=111-125 Localinfection(minor) NNH=67DecreaseinUTIinmaleswithriskfactors

NNT=4-6 Severeinfection Extremelyrare

DecreasedacquisitionofHIV NNT=298 Deathfromunrecognizedbleeding

Extremelyrare

DecreasedacquisitionofHSV NNT=16 Unsatisfactorycosmeticresults

DecreasedacquisitionofHPV NNT=5 Meatalstenosis <1%whenpetroleumjellyisusedOtherwiseNNH=10-50

Decreasedpenilecancerrisk NNT=900-322,000 Decreasedcervicalcancerriskinfemalepartners

NNT=90-140

ReprintedandmodifiedfromtheCanadianPediatricSociety30GroupBStreptococciGroupBstreptococci(GBS)arecommongrampositivecolonizers,affecting10-30%ofwomen.Itisamajorcauseofsepsisamongnewborns.Screeningandtreatmenthavebeenfoundtoreducemorbidityandmortalityby70%.Accordingly,womenshouldbescreenedforGBScolonizationat35-37weeksusingculturetakenfromoneswabfirsttothevaginaandthentotherectumthroughtheanalsphincter.ThisrecommendationappliestowomenwithplannedC-sectionsaswellduetotheriskofruptureofmembranesbeforethescheduleddate.


IndicationsforintrapartumIVantibioticprophylaxisforGBS:

• Positivevaginal/rectalGBSswabat35-37weeks• Pretermprematureruptureofmembraneorlabourunlessnegativeswabdocumented• Prolongedruptureofmembrane>18hoursunlessnegativeswabdocumented• AnywomanwithaninfantpreviouslyinfectedwithGBS• AnywomanwithdocumentedGBSbacteruria(regardlessofCFUs)inthecurrentpregnancy

Shouldeitherofthelattertwoindicationsbepresent,aswabisunnecessaryasitwillnotaffectmanagement.Recommendedantibioticregimensforintrapartumprophylaxisinclude:

• Firstline:PenicillinG5millionunitsIV,then2.5-3millionunitsq4huntildelivery• Ifallergictopenicillinbutlowriskofanaphylaxis:cefazolin2gIV,then1gq8huntildelivery• Ifsevereallergytopenicillin:clindamycin900mgIVq8horvancomycin1gIVq12huntildelivery

Forallwomenwithseverepenicillinallergies,antibioticsusceptibilitytestingforGBSshouldbeexplicitlyrequestedontherequisitionwhentheswabisdone.Regardlessofalternateregimen,allneonatesnottreatedwithpenicillinwillrequireaNICUconsult,astheyareconsideredtohavehadinadequateprophylaxis.31GenitalHSVProphylaxisPrimaryinfectionwithHSV1orHSV2inthe3rdtrimesterpresentsthehighestrisktotheinfant(30-50%)andisanindicationforelectiveC-section.NeonatalculturesforHSVshouldbeperformedfollowingdelivery.Recurrentinfectioncarriesa2-5%riskofneonatalinfectionwhenHSVlesionsarepresent.Toreducetheriskofoutbreakandasymptomaticshedding,suppressiveantiviralsshouldbestartedat36weeks.Ifdiseaseissevere,antiviralsmaybestartedanytimeduringpregnancy.Theregimensofchoiceinclude:

• Acyclovir400mgpoTIDor200mgpoQID• Valacyclovir500mgpoBID

Iflesionsarepresentatthetimeofdelivery,C-sectionisrecommendedwithinfourhoursofruptureofmembranes.Ifnolesionsarevisible,scalpelectrodesandfetalscalpsamplingshouldstillbeavoided.32SignsofLabourTheonsetoflabourisdefinedasregular,painfuluterinecontractionsresultinginprogressivecervicaleffacementanddilatation.Womenshouldbeadvisedtocometotriageif:

• Contractionsq5mininprimiporq10mininmultip• Unabletowithstandpainofcontractions• Spontaneousruptureofmembrane

o Within12hoursifGBS–veo ImmediatelyifGBS+veorpreterm

• Bleeding,decreasedfetalmovements,etc.33InductionofLabourInductionoflabouristheartificialinitiationoflabourbeforeitsspontaneousonset.Inductionisindicatedwhentheriskofcontinuingthepregnancyforthemotherandfetusisgreaterthantheriskassociatedwithaninduction.


Inductionoflabourmaybeassociatedwithanincreasedriskof:• Failuretoachievelabour• C-section• Operativevaginal

delivery• Tachysystole• Intra-amnioticinfection• Cordprolapsewith

artificialruptureofmembrane

• UterineruptureSeveralvariableswillimpactthetimingandtechniquesusedforinduction.

ConsiderationsforInductionIndications Contraindications• Preeclampsia≥37weeks• Intra-amnioticinfection• Suspectedfetalcompromise• Prematureruptureofmembranes• Postdates>41weeks• Diabetesmellitus• Alloimmunedisease• IUGR• Oligohydramnios• GHTN≥38weeks• Logisticalproblem(ex:distancetohospital)

• Intrauterinedeathinpriorpregnancy

• Placentaprevia• Vasaprevia• Cordpresentation• Abnormalfetallie• PriorclassicalorinvertedTuterineincision

• Significantprioruterinesurgery• Previousuterinerupture• Activegenitalherpes• Pelvicstructuraldeformities• Invasivecarcinomainsitu



References(draft)SocietyofObstetriciansandGynecologistsofCanada(SOGC):

• AdolescentPregnancyGuidelines(2015)• ChorionicVillusSampling,EarlyAmniocentesis,andTerminationofPregnancyWithoutDiagnosticTesting:

ComparisonofFetalRiskFollowingPositiveNon-invasivePrenatalTesting(2016)• DeterminationofGestationalAgebyUltrasound(2014)• DiabetesinPregnancy(2016)• FetalSoftMarkersinObstetricUltrasound(2005)• GuidelinesfortheManagementofaPregnantTraumaPatient(2015)• InductionofLabour(2013)• IntrauterineGrowthRestriction:Screening,Diagnosis,andManagement(2013)• ManagementofSpontaneousLabouratTerminHealthyWomen(2016)• Mid-TrimesterAmniocentesisFetalLossRate(2007)• Pre-conceptionFolicAcidandMultivitaminSupplementationforthePrimaryandSecondaryPreventionof

NeuralTubeDefectsandOtherFolicAcid-SensitiveCongenitalAnomalies(2015)• TheManagementofNauseaandVomitingofPregnancy(2016)• ThePreventionofEarly-OnsetNeonatalGroupBStreptococcalDisease(2013)• UltrasoundEvaluationofFirstTrimesterComplicationsofPregnancy(2016)• UmbilicalCordBlood-Counselling,Collection,andBanking(2015)• No.129–ExerciseinPregnancyandthePostpartumPeriod(2018)• No.133–PreventionofRhAlloimmunization(2018)• No.148–GuidelinesforOperativeVaginalBirth(2018)• No.155–GuidelinesforVaginalBirthafterPreviousCaesareanBirth(2018)• No.185–HIVScreeninginPregnancy(2017)• No.203–RubellainPregnancy(2018)• No.208–GuidelinesfortheManagementofHerpesSimplexVirusinPregnancy(2017)• No.211–ScreeningandManagementofBacterialVaginosisinPregnancy(2017)• No.214–GuidelinesfortheManagementofPregnancyat41+0to42+0Weeks(2017)• No.223–ContentofaCompleteRoutineSecondTrimesterObstetricalUltrasoundExaminationand

Report(2017)• No.231–GuidelinesfortheManagementofVasaPrevia(2017)• No.239–ObesityinPregnancy(2018)• No.245–AlcoholUseandPregnancyConsensusClinicalGuidelines(2017)• No.257–UltrasonographicCervicalLengthAssessmentinPredictingPretermBirthinSingleton

Pregnancies• No.261–PrenatalScreeningforFetalAneuploidyinSingletonPregnancies(2017)• No.274–ManagementofVaricellaInfection(Chickenpox)inPregnancy(2018)• No.276–ManagementofGroupBStreptococcalBacteriuriainPregnancy(2018)• No.285–ToxoplasmosisinPregnancy-Prevention,Screening,andTreatment(2018)• No.298–ThePreventionofEarly-OnsetNeonatalGroupBStreptococcalDisease(2018)• No.342–HepatitisBandPregnancy(2017)• No.348-JointSOGC-CCMGGuideline:UpdateonPrenatalScreeningforFetalAneuploidy,Fetal

Anomalies,andAdversePregnancyOutcomes(2017)• No.349–SubstanceUseinPregnancy(2017)• No.354–CanadianHIVPregnancyPlanningGuidelines(2018)• No.355–PhysiologicBasisofPaininLabourandDelivery:AnEvidence-BasedApproachtoIts

Management(2018)


• No.357–ImmunizationinPregnancy(2018)• No.359–ObstetricUltrasoundBiologicalEffectsandSafety(2018)• No.361–CaesareanDeliveryonMaternalRequest(2018)• No.363–InvestigationandManagementofNon-immuneFetalHydrops(2018)

NationalAdvisoryCommitteeonImmunization:

• ASummaryoftheNACIUpdateonImmunizationinPregnancywithTetanusToxoid,ReducedDiphtheriaToxoidandReducedAcellularPertussis(Tdap)Vaccine(2018)

CanadianJournalofDiabetes:

• DiabetesandPregnancy(2018)

HealthCanada

• https://www.canada.ca/en/health-canada/services/food-nutrition/food-safety/food-additives/caffeine-foods/foods.html

• https://www.canada.ca/en/health-canada.html

GECKO

AmericanThyroidAssociation

• 2017GuidelinesoftheAmericanThyroidAssociationfortheDiagnosisandManagementofThyroidDiseaseDuringPregnancyandthePostpartum

NEJM

• Wapner,RonaldJ.,etal.“ChromosomalMicroarrayversusKaryotypingforPrenatalDiagnosis.”NewEnglandJournalofMedicine,vol.367,no.23,2012,pp.2175–2184.,doi:10.1056/nejmoa1203382.

PhysicalActivityReadinessMedicalExamforPregnancy• www.csep.ca/

MountSinaiHospital

• http://womensandinfantshealth.ca/fetal-medicine/placenta/

AmericanAcademyofPediatrics

• Ryan,SherylA.,etal.“MarijuanaUseDuringPregnancyandBreastfeeding:ImplicationsforNeonatalandChildhoodOutcomes.”Pediatrics,vol.142,no.3,2018,doi:10.1542/peds.2018-1889.

Documents

DFCM ROUTINE PRENATAL CHECKLISTthehub.utoronto.ca/family/wp-content/uploads/2016/... · Smoking is associated with spontaneous abortion, preterm labour, premature rupture of membrane,