FUNDAMENTALS OF OBSTETRICS

Christine Pecci, MD

UCSF Department of Family and Community Medicine

March 2016

No disclosures

OBJECTIVES

Review criteria for ultrasound vs LMP dating

List healthy practices in pregnancy

Describe guidelines for diagnosis, treatment and

management of preeclampsia and diabetes

List infections in pregnancy and how to manage

or prevent these from occurring

Tanya is a 23 yo G1P0 who presents for early

pregnancy care. This is a planned pregnancy.

She is 10 1/7 wks by a sure LMP

She had some bleeding yesterday and went to ED

where she had an US that puts her at 9 2/7

weeks today (6 days different than EDD based on

LMP)

Reports regular menses q month

Should you change her dating based on 1st

trimester US?

DATING

Gestational Age Discrepancy for re-dating w

US date

< 9 weeks > 5 days (CRL)

9 weeks to < 14 weeks > 7 days (CRL)

14 weeks to < 16 weeks > 7 days (BPD, HC, AC, FL)

16 weeks to < 22 weeks > 10 days

22 weeks to < 28 weeks > 14 days

28 weeks and beyond > 21 days

ACOG Committee Opinion Oct 2014

Single uniform standard based on expert opinion (ACOG, AIUM, SMFM)

EDD=280 days after first day LMP

Half of women accurately remember LMP

40% adjustment in 1st trimester; 10% adjustment 2nd trimester

Use earliest US

We confirm that Tanya has a “sure” LMP

We will calculate her EDD based on her LMP

US discrepancy is 6 days but between 9-14 weeks

we would use the US based EDD only if it differs

by >7 days

WILL MY BABY BE NORMAL?

She has been reading about a new test for

making sure the baby is normal. She wants to

know if you can order this test. Will having a

normal test guarantee that this baby will be

okay?

ANEUPLOIDY SCREENING

First trimester 10-15 weeks

Serum testing (free bhg + PAPP-A)

Ultrasound (NT)

Second trimester screening 15-20 weeks

Serum testing (AFP, inhibin, bhcg, estriol)

Ultrasound (fetal survey)

Step-wise vs integrated testing

NOT diagnostic (need CVS or Amniocentesis)

NON-INVASIVE PRENATAL TESTING

(NIPT)

Cell free fetal DNA

Comes from placental cells and clears from

maternal system in hours

Tests for Trisomy 18, 21, 13

Can be checked 10 – 22 weeks gestation

Only for high risk patients

Age >35, abn US, history of trisomy, parent with

balanced translocation

If positive result, refer to genetic counseling and

offer invasive testing

False positive 0.5%, 98-99% Trisomy 21 detected

HOW DO I STAY HEALTHY DURING

PREGNANCY?

IOM WEIGHT GAIN GUIDELINES

Pre Preg BMI BMI Total Weight Gain

Underweight <18.5 28-40

Normal 18.5-24.9 25-35

Overweight 25.0-29.9 15-25

Obese >30 11-20

Institute of Medicine 2009

EXERCISE IN PREGNANCY

Goal: 30 minutes most days of the week

If sedentary, start out slowly ie 5 min daily

Avoid contact sports or high risk of falling

Avoid sports that involve balance changes

No scuba diving

Keep off back, drink lots of water

Listen to your body

NUTRITION IN PREGNANCY

Folic Acid: 600 mcg folic acid

Iron: 27 mg

Calcium: 1000-1300 mg

Vit D: 600 IU

ACOG Sept 2013

I love hot dogs!

Pregnant women more likely to be affected

Avoid refrigerated smoked seafood, pate,

unpasteurized milk/cheese

Deli meats/hot dogs need to be steaming hot

I LOVE MY CAT!

Ingestion of raw/undercooked meat, unwashed

fruits/vegetables, soil or litter contaminated with

cat feces

Wash hands

Have someone else clean cat litter

Use gloves

Change litter box daily

Do not feed raw meat to cats

I’M GLAD I DON’T LIKE FISH!

Fish is good for you and provides necessary

nutrients for growing fetus

Should eat on average two meals a week

8-12 oz of fish/shellfish a week

Avoid swordfish, tilefish, king mackerel, shark

DISEASES IN PREGNANCY

I’M SO NERVOUS…

Tanya is worried specifically about preeclampsia

because her sister had it and needed to be

induced a few weeks before her due date.

“Is there anything that you can give me so that I

don’t get this disease too?”

PREECLAMPSIA: YOU WILL SEE IT!

Incidence 2-8%

Has increased by 25% in last two decades

More likely in patients with hypertension

Unrecognized has serious health consequences

for mom and baby

Risk factor for future CV and metabolic disease

Task Force for Hypertension in

Pregnancy, 2013

WHO SHOULD TAKE ASA?

Initiate ASA 81 mg in late first trimester

History of preeclampsia < 34 0/7 weeks

Preeclampsia in more than one pregnancy

Patient with history of preeclampsia <34 wks

Prevalence 40%

NNT 1:20 (moderate Q; qualified SOR)

NNT 1:500 low risk (prev 2%)

NNT 1:50 high risk (prev 20%)

TASK FORCE FOR HYPERTENSION

IN PREGNANCY, 2013

17 experts (OB, MFM, htn, nephrology,

anesthesia, physiology, patient advocacy)

Changes in terminology

Changes in management

CATEGORIES

Preeclampsia-eclampsia

With or without severe features

Chronic hypertension

Gestational hypertension- hypertension without

proteinuria after 20 week

Chronic hypertension with superimposed

preeclampsia

Task Force for Hypertension in Pregnancy,

2013

PROTEINURIA

>300 mg in 24 hrs

Spot urine:creatinine ratio > 0.3

Dipstick 1+

Proteinuria is classically part of the syndrome

But NOT required to make diagnosis of

preeclampsia

DIAGNOSIS

Elevated BP

>140/90 on two occasions 4 hours apart

Proteinuria or “severe features”

>160/110

Plts <100K

LFTs twice normal

Persistent RUQ pain or epigastric pain

Creatinine >1.1 or double

Pulmonary edema

New onset cerebral or visual disturbance

MANAGEMENT

Chronic hypertension

Deliver after 38 0/7 wks

Gestational hypertension:

Deliver at 37 0/7 weeks

weekly dip for proteinuria + BP check (can be at

home)

NST q week

MANAGEMENT

Preeclampsia without severe features:

Deliver at 37 0/7 weeks

2x week BP, once a week labs

2x week NST

Preeclampsia with severe features

Deliver at 34 0/7 weeks

Monitor in hospital

Severe uncontrolled htn, eclampsia, pulm edema,

abruption, DIC, NRFHR, IUFD

Immediate delivery after initial stabilization

INTRAPARTUM INTERVENTIONS

Mg with severe preeclampsia only (low/qual)

Anti hypertensive meds only for > 160/110

(mod/strong)

Administer steroids prior to delivery (high/

strong)

POSTPARTUM FOLLOW-UP

Incidence unknown

ALL patient should receive education on warning

signs

Check BP 72 hours post delivery and 7-10 days

postpartum

Treat for >150/100 on two occasions 4-6 hrs apart

Preconception- glycemic control, weight loss

DIABETES IN PREGNANCY

Overall incidence of diabetes in pregnancy 6%

90% of these are GDM

HAPO trials show continuous relationship-

neonatal hypoglycemia, macrosomia

Increased hyperbilirubinemia, operative delivery,

shoulder dystocia

ACOG Practice Bulletin Aug 2013

GESTATIONAL DIABETES

Screen at 24-28 wks

Early screening- if prior GDM, known impaired

fasting glucose, BMI >30

2010 International Association of Diabetes and

Pregnancy Study Group (endorsed by ADA) (92,

180, 153)

No data regarding therapeutic intervention

DIAGNOSIS

2013 NICHD recommends 2 step test (50 gm

then 100 gm)

Consider prevalence of diabetes

Consider resources

One hour glucola: range 135-140

fasting 1 hr 2hr 3hr

NDDG* 105 190 165 155

CC** 95 185 165 140

*National Diabetes Data Group

**Carpenter Coustan

TREATMENT

QID fingersticks

ADA and ACOG 140 on 3 hr and 120 2 hr

Carbs 33-40% of diet; Protein 20%; fat 40%

Moderate exercise

If fasting consistently >95, consider insulin

Insulin does not cross the placenta

Glyburide and metformin

not approved but being used

Glyburide crosses placenta but no measurable

levels in cord blood

MODE OF DELIVERY WITH DIABETES

Prevention of a single permanent brachial plexus

palsy

Cesarean delivery for 4500 gm NNT 588

Cesarean delivery for 4000 gm NNT 962

POSTPARTUM FOLLOW-UP

15-50% with GDM develop DM 20+ years later

Varies by ethnicity (60% Latina within 5 years)

Fasting or 2 hr GTT 6-12 wk postpartum

IGT picked up by 2 hr

Repeat testing q 3 years if normal

INFECTIONS IN PREGNANCY

HSV

Genital herpes affects 20% women in US?

Incidence of new infection in preg 2%

Women with recurrent HSV-75% can expect

episode during preg, 14% at delivery

80% of infected infants born to women with no

reported history

20% neonatal survivors have long-term

neurosequealae

HSV-GIVE PROPHYLAXIS AT TERM

Primary infection transmission - 30-60% at delivery

Recurrent infection transmission 3% at delivery; no

lesions 2/10,000

Acyclovir, famcyclovir, valcyclovir all class B, most

data on acyclovir

Routine screening not recommended

Genital Sx or lesions- c/s decreases transmission from

7.2% to 1.2% even after ROM

Acyclovir 400 mg TID @ 36

weeks til delivery

HIV

Opt out screening for ALL women

Low threshold for repeating in third trimester; offer

testing on L&D

Early viral suppression is of upmost importance

Elective cesarean if VL >1000 near delivery

Intrapartum AZT unless consistent VL <1000

Neonatal AZT prophylaxis required for 4-6 weeks

add if NVP high risk

Consider offering presumptive treatment (AZT+NVP+3TC)

No breastfeeding (developed countries)

Clinician Consultation Center Perinatal hotline 24/7

http://nccc.ucsf.edu/

GBS

Screen all women at 35-37 wks, unless

Previous child with early onset GBS disease

GBS bacteruria in index pregnancy

Treat with intrapartum IV penicillin first line

Ask for sensitivities if has pcn anaphylaxis to see if

can give Clinda/erythro

Cefazolin if no anaphylaxis reaction to penicillin

Vanco reserved for those with anaphylaxis or those

without sensitivities

Adequate treatment >4 hours pcn or cefazolin

ZIKA VIRUS Transmitted by Aedes species of mosquitos

-also transmit dengue fever, chikunguya viruses

Incubation period 3-12 days

Symptoms 2 or more of following

-fever, rash, arthralgia or conjunctivitis

Can be transmitted in all trimesters

Sexual transmission has been documented via semen

ZIKA VIRUS

Prior to 2007, only sporadic cases in Africa

2007 first outbreak in Federated States of Micronesia (Yap Island)

2013-2014 French Polynesia

First outbreak in Americas- May 2015

February 1, 2016, the World Health Organization declared a Public Health Emergency of International Concern (PHEIC) because of clusters of microcephaly and other neurological disorders in some areas affected by Zika

February 8, 2016, President Obama announced a request for $1.8 billion in emergency funds for several agencies to accelerate research into a vaccine and educate populations at risk for disease.

Countries with reported local transmission

• As of Jan 23, 2016 (CDC slide set)

ZIKA VIRUS

Consider postponing travel if pregnant

Ask about travel to endemic countries

Test those with clinical illnesses (2 or more sx)

during or within 2 weeks of travel

Zika virus RT PCR and Zika Ig M

Offer testing to pregnant women 2-12 weeks after

travel with Zika IgM

Testing done by CDC and state health depts

http://www.cdc.gov/zika/

ZIKA AND FETAL MONITORING

Get ultrasound 3-4 weeks within exposure

Serial scans q 3-4 wks

Offer amnio in documented infection

unknown how long positive or ability of test to

determine fetal injury

Send fetal tissue/placenta

Ok to breastfeed

49

RUBELLA

Do not give during pregnancy and avoid pregnancy x

28 days

Not an indication for termination

If lab evidence of immunity, no need to repeat

If neg or equivocal titer after 1-2 doses, give third dose

and stop checking titers

Ok for children of pregnant women to get

May give with Rhogam, check titer in 3 months

MMWR June 2013

VARICELLA

Lab evidence of immunity or

disease

Birth in US before 1980 is not

sufficient for pregnant women

Diagnosis or verification of

history of varicella or zoster by

health care provider

Should have link to a typical

case or lab confirmation if

testing done during acute

infection

Mary is 36 yo G2P2 delivered 2 days ago via

cesarean delivery. She had declined the Tdap

and flu shot pregnancy because she was afraid of

it hurting the baby. Now she is willing to accept

these two immunizations if you still recommend

them. She got the flu shot last season and got a

Tdap after her last pregnancy in 2011.

Which immunizations would you give her?

TDAP IN EACH PREGNANCY

Tdap is indicated in EVERY pregnancy 27-36

wks EGA for transmission of antibodies to fetus

Once baby is out, indication for Tdap is based on

maternal indications; she is up to date

Flu shot is indicated

SUMMARY

Establish accurate dating

Provide primary care

Immunizations, healthy lifestyles

Watch for pregnancy related diseases

Translates to risk of these diseases later in life

We have interventions to prevent perinatal

transmission of disease