Clinical Guideline: Routine and High Risk Prenatal Care

Transcription

1 Clinical Guideline: Routine and High Risk Prenatal Care Relevance to Population: Two maternal risk factors which can affect prenatal care are smoking and depression. Smoking is associated with increased perinatal mortality, ectopic pregnancy and bleeding complications of pregnancy and a higher incidence of small, low birth weight babies and preterm deliveries. Untreated depression has been associated with unfavorable health behaviors in pregnancy and subsequent fetal growth restrictions, preterm deliveries, placental abruption, and newborn irritability. With early identification of maternal risk factors, Health Options can make an impact on reducing risk factors that can lead to poor pregnancy outcome, low birth weight and infant mortality. Population Covered by Guideline: All pregnant women Key Clinical Indicators: The following summarize the key clinical indicators of the guideline. Clinical Indicators Measured by Delaware Health Options are: 1) Frequency of on-going prenatal visits. 2) Timeliness of Prenatal Care 3) Postpartum Care Prenatal Visits Clinical Indicator Frequency of Monitoring Goal Every 4 weeks for the first 28 to 30 weeks of Prenatal care visit in 1 st trimester or within pregnancy 42 days of enrollment Every 2-3 weeks until 36 weeks of gestation. Equal to or greater than 80% of expected Weekly after 36 weeks of gestation prenatal visit. (ACOG recommends 14 visits) Frequency of follow up visits determined by the Monitor progression of the pregnancy, detect individual woman s needs and assessment of her risk medical and psychosocial complications and factors institute indicated interventions Postpartum visit Early identification and intervention of high risk factors Postpartum visit on or between 21 days and 56 days after delivery Risk profiles Preconception visit First prenatal visit; including completion of OB Needs Assessment Form (ONAF) Submission of additional ONAF for any changes in risk status Submission of 2 nd ONAF at weeks gestation To increase women s awareness of reproductive risk and health enhancing behaviors to improve the outcome of pregnancy Early identification of risk factors that lead to poor pregnancy outcomes

2 Clinical Indicator Frequency of Monitoring Goal Submission of 3 rd ONAF at postpartum visit TSH Free T4 every trimester for those at risk for overt hypothyroidism Coordination of care with MOM Options Case Management for all high risk members Ongoing assessment of high-risk conditions at each visit 2 nd screening for preterm labor and birth 3 rd screening to identify postpartum issues example depression Psychological and psychosocial assessment Weight These recommendations are for the general obstetrical population in the United States. Every visit Singleton pregnancy BMI <18.5 kg/m2 (underweight) weight gain 28 to 40 lbs (12.5 to 18.0 kg) BMI 18.5 to 24.9 kg/m2 (normal weight) weight gain 25 to 35 lbs (11.5 to 16.0 kg) BMI 25.0 to 29.9 kg/m2 (overweight) weight gain 15 to 25 lbs (7.0 to 11.5 kg) BMI 30.0 kg/m2 (obese) weight gain 11 to 20 lbs (5 to 9.0 kg) Twin pregnancy BMI <18.5 kg/m2 (underweight) no recommendation due to insufficient data BMI 18.5 to 24.9 kg/m2 (normal weight) weight gain 37 to 54 lbs (16.8 to 24.5 kg) BMI 25.0 to 29.9 kg/m2 (overweight) weight gain 31 to 50 lbs (14.1 to 22.7 kg) BMI 30.0 kg/m2 (obese) weight gain 25 to 42 lbs (11.4 to 19.1 kg) Blood Pressure Every visit Systolic < 140 and Diastolic 90mmHG Fetal assessment Every visit from the 10 week visit on Assessment of fetal heart rate, fundal height, growth, movement, contractions, and fetal position

3 Laboratory screening: Universal 1) CBC with platelets 2) Blood type and screen including Rh type 3) Antibody Screen 4) RPR 1) Initial visit and repeat Hct/Hgb at week gestation 2) Initial visit 3) Initial visit and repeat at 28 weeks gestation for unsensitized, D negative individuals. [If second antibody test for Rh negative, give prophylactic Rhogam] 4) Initial visit and repeat at 28 weeks if at risk, during third trimester, at delivery of a still born child Improve the frequency of appropriate testing during pregnancy 5) Rubella antibody titer (immunity) 6) Urinalysis, including microscopic exam 7) Urine culture 8) Hepatitis B surface antigen 9) Universal HIV Screening 10) Cervical cytology, screening for gonorrhea and Chlamydia 11) Urine dip for glucose and protein 12) Group B beta strep screening 13) Diabetes screening 14) Offer MSAFP/multiple markers 15) Offer screening for aneuploidy and neural tube defect. (nuchal translucency, biochemical markers, CVS, HCG, unconjugated estriol, Inhibin A screening and/or amniocentesis as appropriate) 16) Nuchal thickness with blood work markers. 17) Quad Screen 18) MaterniT21 for high risk indicators 19) Anatomical ultrasound 20) Cystic Fibrosis Screening 21) Fragile X-syndrome screening 22) Genetic screening 23) Varicella antibody titer if negative history of disease or unknown 5) Initial visit 6) Initial visit 7) Initial visit 8) Initial visit 9) Universal HIV testing in prenatal care for all patients, with an option to opt-out. 10) Initiate at 21 years of age 11) Each visit 12) Screen at weeks 13) Screen at weeks, earlier if risk factors present, screen for fetal macrosomia (pt or previous pregnancy), history of GDM, if GDM or current pregnancy follow up in 5-12 weeks, known impaired glucose metabolism or Obesity (BMI 30). 14) weeks and up to 22 6/7 th week 15) First-second trimester as indicated 16) 10 6/7 13 6/7 weeks 17) 15 0/7 to 21 6/7 weeks 18) 10 0/7 to 30 weeks, Age 35 or older, Structural abnormalities, family history of Down s Syndrome, Positive Screening. 19) weeks gestation, repeat if indicated. If dating unsure consider earlier ultrasound. 20) First Trimester Screen regardless of family history 21) First Trimester Screen regardless of family history 22) First Trimester Screen regardless of family history 23) Immunize postpartum if titer is low or negative

4 Clinical Indicator Frequency of Monitoring Goal Laboratory Screening: Risk Based 1) Hepatitis C antibody 1) Initially for high risk, e.g., tattoos, history of IV drug Reduce Maternal and Neonatal Morbidity use 2) Hemoglobin electrophoresis 3) Urine drug screen based on history 4) Screen for bacterial vaginosis 5) Zika PCR 6) One hr 50 gm glucose 2) Individuals of African descent at risk for sickle cell trait should have hemoglobin electrophoresis: - Solubility tests (Sickledex) alone are not adequate for screening; - Individuals of Southeast Asian, Mediterranean descent, and with MCV<80 should have hemoglobin electrophoresis - Other individual at risk 3) If indicated 4) If history of preterm labor 5) travel to endemic area or exposure 6) initial prenatal visit if risk factors for GDM exist (e.g. previous babies with macrosomia, shoulder dystocia) Immunization Delaware Health Options follows the Centers for Disease Control and Prevention. Recommended Adult Immunization Schedule-United States, ) Influenza all trimesters 2) Tdap: between 27 and 36 weeks. Reduce the risk of disease and complications in susceptible women and/or fetus/neonate Counseling & Education 1) Nutrition, folic acid supplement, and obesity 2) Dental care 3) Substance use: tobacco smoke, alcohol, illicit drugs, and over-counter drugs 4) Effects of second hand smoke 5) Physical activity/life style 6) Domestic violence and abuse 7) Sexual practices and STDs 8) Preterm birth prevention- consider progesterone support for previous spontaneous preterm birth 9) Physiology of pregnancy, expect course of care 10) Self-help for discomforts 11) Breast feeding 12) Child birth education classes 13) Maintaining good control of preexisting medical conditions 1-17 Every visit Increase the percentage of women who are screened and advised regarding the increase risk of poor pregnancy outcomes with obesity Increase the percentage of pregnant women who receive timely counseling and education on smoking, exposure to second hand smoke. For smokers to quit and are offered cessation counseling Increase education of members who are pregnant

5 14) Labor and delivery 15) Aspects of postpartum care and newborn care 16) Necessary preparations for hospital 17) Resources available 18) Depression (monitor prenatal & postpartum) 19) Any other risk assessed/identified on ONAF 20) Travel 21) Nutrition and Exercise 18) Every trimester and postpartum 19) Every visit Increase the percentage of women who receive screening and treatment for perinatal depression Scientific Evidence Sources: The American College of Obstetricians and Gynecologists. Committee on Obstetric Practice the following Committee Opinions: Prevention of Early-Onset Group B Streptcoccal Disease in Newborns. Committee Opinion #485, April 2011 reaffirmed 2014; Routine Human Immunodeficiency Virus Screening, Committee Opinion #411, August 2008 reaffirmed 2010; Update on Carrier Screening for Cystic Fibrosis. Committee Opinion # 486., April 2011; Screening for Tay Sachs Disease. Committee Opinion Number 318., October 2005 reaffirmed 2014; Carrier Screening for Fragile X Syndrome, Committee Opinion Number 469, October 2010 reaffirmed 2014;Psychological Risk Factors: Perinatal Screening and Intervention, Committee Opinion, Vol No. 2, August Screening for depression during pregnancy, Committee Opinion No. 630, Retrieved May The American College of Obstetricians and Gynecologists. Committee on Obstetric Practice the following Practice Bulletins: Anemia in Pregnancy, Number 95, July 2008; Screening for Fetal Chromosomal Abnormalities, Number 77, January 2007 reaffirmed 2014 Neural Tube Defects, Number 44, July 2003; reaffirmed 2014 Pregestational Diabetes Mellitus, Number 60, March 2005, Reaffirmed 2014 Hemoglobinopathies in Pregnancy, Number 78, January 2007 reaffirmed 2015 Viral Hepatitis in Pregnancy, Number 86, October 2007, Reaffirmed 2014 Gestational Diabetes Mellitus ACOG Practice Bulletin Number 137, August 2013, Reaffirmed 2015 TSH Free T4, Number 148, April 2015 Obesity in Pregnancy, Number 2015, December 2015, Critical Care in Pregnancy, Number 158, January 2016 The American College of Obstetricians and Gynecologists. Committee on Obstetric Practice the following Frequently Asked Questions Reports: FAQ 133 January 2016 The American College of Obstetricians and Gynecologists. Committee on Obstetric Practice the following Frequently Asked Questions Reports: FAQ 165 April 2014 American College of Obstetrics and Gynecology, Guidelines for Prenatal Care 6 th edition, (2007) Retrieved May 5, 2012 from Weight Gain During Pregnancy: Reexamining the Guidelines. Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines, Rasmussen KM, Yaktine AL (Eds), National Academies Press (US), The National Academies Collection: Reports funded by National Institutes of Health, Washington (DC) Available at: Reprinted with permission from: the National Academies Press, Copyright 2009 National Academy of Sciences. The American Society for Colposcopy and Cervical Pathology (ASCCP). Management and Screening Guidelines 2012 Standards. Health Care Guideline: Routine Prenatal Care: Institute for Clinical Systems Improvement; July 2012.

6 American Diabetes Association (ADA) Standards of Medical Care in Diabetes January 2015; Sexually Transmitted Diseases Treatment Guidelines, Morbidity and Mortality Weekly Report. December 17, 2010/ Vol.59/No. RR Gov/mmwr. The 2015 schedule was approved by the Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP); American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse-Midwives (ACNM). Link: