Академический Документы
Профессиональный Документы
Культура Документы
Prenatal Care
Prenatal Care
Practices to continue
Underperformed practices
Practices of questionable value
Prenatal Care
Prenatal Care
Preconception counseling:
Folic acid: 50-70% risk reduction for NTD.
Control of blood sugars & pressures
(Avoid contraindicated medications).
Dietary control for women with phenylketonuria.
CDC recommended
V26.49 (procreative management counseling)
11/8/2012
Prenatal Care
Questionable Value?
Practices to continue:
Blood pressure:
R/o chronic hypertension at initial visit
Screen for preeclampsia after 20 weeks
Screening:
Initial visit prenatal laboratory examination
2nd and 3rd trimester labs
Pregnancy Test
Prenatal Labs
at First OB visit
Differential diagnosis
Expected Result
Blood type
A, B, AB, O
Clinical Utility
Transfusion
Rh and Ab screen
H/H
Rh +/-; negative
> 11.5 g/dL
Alloimmunization
Anemia
MCV
> 80 fL
Hemoglobinopathy
PAP
Normal cytology
Cervical cancer
Rubella/Varicella IgG
Immune
Exposure/pp vaccine
Urine Culture
Negative
Asx Bacteriuria
Syphilis testing
Negative
Treatment
HBsAg testing
Negative
Prev transmission
Chlamydia testing
Negative
Treatment
HIV testing
Negative
Treatment
11/8/2012
Disease associations
Subjects with blood groups A, B, or AB have a higher
risk of venous thromboembolic disease than those of
blood group O (RR = 3.7)
Rh blood group
Rh blood group
Rh + or Rh
Technically correct nomenclature:
Rh(D) positive or Rh(D) negative.
Caucasians.. DCe
African-Americans.. Dce
Anti-Rh(D) immunoglobulin
Sterile solution containing IgG anti-D (anti-Rh) manufactured
from human plasma (not recombinant).
Many brand names:
HyperRHO
RhoGAM
Rhophylac
WinRho
11/8/2012
Anti-Rh(D) immunoglobulin
When & how much?
Anti-Rh(D) immunoglobulin
Anti-Rh(D) immunoglobulin
After delivery:
11/8/2012
SensiGene
MaterniT21
Intended use
Trisomy 21
Sample type
Whole blood
Whole blood
EGA (wks)
Collection requirements
> 10 wk
10 wks
2 x 10 mL tubes
(EDTA lavender top)
2 x 10 mL tubes
(Mottled black/tan top
cell-free DNA)
Storage/shipment
Do not freeze/
Ship same day
Do not freeze/
ship same day
Turnaround time
7 business days
10 business days
$ 25
Cost to patient if
no full insurance coverage
Copyright 2012 Obstetrics & Gynecology. Published by Lippincott Williams & Wilkins.
30
11/8/2012
Hemoglobin
Hemoglobin
High Hemoglobin
Objectives:
Detect anemia
Screen for hemoglobinopathies
Differential diagnosis:
High altitude
Advanced cardio-pulmonary disease
Myeloproliferative disorders
Polycythemia
Erythropoietin secreting tumor
Anemia in pregnancy:
First and third trimester:
Second trimester:
Hb levels <10.5 g/dL and Hct levels <32%
Alcoholism
Liver disease
Hypothyroidism
Myelodysplastic syndromes
Aplastic anemia
Medications (AZT, INH, MTX, Bactrim)
11/8/2012
Ferritin
Thalassemia
Hemoglobinopathy
Anemia of Chronic Disease
Other: Lead poisoning, G6PD, PNH
False low MCV: Fragmentation of RBCs
Mentzer Index:
MCV/RBC count < 13 favors thalassemia over IDA
Check Ferritin
IDA - Management
Low ferritin:
IDA
9-11
<9
w/u & Rx
Hemoglobinopathies
Peripheral smear
Reticulocyte count
Direct Coombs
Hematology consult; bone marrow exam?
11/8/2012
Hemoglobin Electrophoresis
Parent history:
History of anemia
Previous stillbirth
Family history:
Hemoglobinopathy or thalassemia
Consanguineous marriages
Maternal MCV:
MCV <80 fL in the absence of iron deficiency
suggests thalassemia
Further testing with hemoglobin electrophoresis is
indicated.
Couple at-risk of
fetal hemoglobinopathy
Sexually Transmitted
Disease
Screening
If solubility first :
It only detects hemoglobin S.
Needs then electrophoresis.
11/8/2012
Estimated Number
Chlamydia
100,000
Gonorrhea
13,200
Hepatitis B
16,000
HIV
6,400
Syphilis
< 1,000
Syphilis
Objective:
Prevent in utero transmission of asymptomatic
infection which can lead to congenital syphilis
Total rate of Congenital Syphilis: 8.7 cases per 100,000 live births
11/8/2012
Treponema pallidum
Darkfield microscopy
Direct fluorescent antibody (DFA)
NAAT (nucleic acid amplification tests): not widely
available
Presumptive diagnosis
10
11/8/2012
= Discordant result
RPR?
or
T. pallidum IgG Ab ?
Traditional
versus
New
EIA/CIA
EIA/CIA
+
RPR
(Reverse Sequence)
RPR
Screening?
TP-PA
+
Syphilis
57 % discordant
TP-PA
Syphilis unlikely*
32 % were false +
Up to 20% of patients
Immunodysregulation of antibody production?
Generally a titer of 1:8 or lower
11
11/8/2012
HIV screening
HIV
12
11/8/2012
Institute of Medicine
Hepatitis B
2010 report:
Most OBs screen for hepatitis B.
Most OBs advise that newborns of +HBsAg
mother receive both hepatitis B vaccine and
hepatitis B IV IgG immediately after birth.
However . . .
Only 1/2 -1/3 referred pregnant +HBsAg pt. to
specialist for management of Chronic Hepatitis B.
Only few follow a systematic approach.
13
11/8/2012
Negative HBsAg
Risk factors for acquiring HBV during pregnancy:
Positive HBsAg
HBsAg (+)
Positive HBsAg
Positive HBsAg
14
11/8/2012
Disease
Antibiotic
Chancroid
Azithomycin
Granuloma Inguinale
Azithomycin
LGV
Erythromycin
Syphilis
Chlamydia
Gonorrhea
HIV
Hepatitis B
Penicillin
Azithomycin
Ceftriaxone
Antiretrovirals
Refer to specialist
Bacterial vaginosis
Metronidazole
Trichomoniasis
Metronidazole
V V Candidiasis
Topical azoles
Genital Warts
N/A
Pediculosis
Permethrin
Scabies
Permethrin
15
11/8/2012
Perform colposcopy
or
Defer until 6 weeks postpartum (preferred).
16
11/8/2012
HGSIL in Pregnancy
Pregnant women with HSIL should undergo prenatal
colposcopy.
Because cervical changes in pregnancy can mimic CIN,
colposcopy should be performed by experienced colposcopist.
Biopsy lesion(s) if suspicious for CIN 2,3 or cancer.
If CIN 2,3 is not found, repeat colposcopy no earlier than
6 weeks postpartum.
If CIN 2,3 is found, repeat cytology and colposcopy may be
performed every 12 weeks with repeat biopsy if the lesion
worsens or cytology suggests invasion.
Endocervical curettage is unacceptable during pregnancy.
Cancer treatment is unacceptable without confirmation of
cancer.
STD screening
What if patient requests anonymous testing?
Urine Tests
17
11/8/2012
Urine Dipstick
Asymptomatic Bacteriuria
Proteinuria:
Dipstick is non-reliable
Random urine P/C ratio
24 hr urine collection: gold standard
GBBS Bacteriuria
Symptomatic bacteriuria and Asymptomatic HIGH
colony counts ( 105 CFU/mL ) Treat.
GBS bacteriuria anytime in pregnancy should routinely
receive prophylactic intrapartum antibiotics (exception for
screening at 35-37 wks).
Antepartum LOW colony counts: < 105 CFU/mL:
Immunity to
Rubella & Varicella
Determination of Immunity
If Non-immune (susceptible)
2%
7%
17%
Susceptibility rates
18
11/8/2012
Postexposure
Varicella Prophylaxis
Prophylaxis with immunoglobulin (VZV-specific
antibodies) is recommended compared with
watchful waiting.
In the U.S., VariZIG is the only available
product with VZV-specific antibodies (it is under
an Investigational New Drug application
Expanded Access Protocol).
Call 1-800-843-7477 (FFF Enterprises, California)
It should not be delayed for 10 days* after exposure
since efficacy beyond this time point is unknown.
No local IRB approval is needed.
MMWR Morb Mortal Wkly Rep. 2012;61(12):212
MMR Susceptibilities
Measles: 17%
Mumps: 16%
Rubella: 9%
33% susceptible to at least on of these viruses
< 2% susceptible to all 3.
Immunizations
General principles
19
11/8/2012
Tdap advertisement
CDC recommends administration of Tdap
during pregnancy to reduce the risk of
maternal pertussis, and thus transmission to
the infant.
Pertussis can be lethal or have significant
morbidity.
Tdap is given after 20 wks.
Notes
References:
US:
ACOG: www.acog.org
DOD/VA: The Management of Uncomplicated Pregnancy Working Group. Clinical
Practice Guideline for the Management of Uncomplicated Pregnancy.
Washington, DC, 2002
AAFP: Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care.
www.aafp.org.
CDC: http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf
Institute for Clinical Systems Improvement (ICSI):
http://www.icsi.org/prenatal_care_4/prenatal_care__routine__full_version__2.html
Outside the US:
UK: National Institute for Health and Clinical Excellence (Antenatal Care: Routine
Care for the Healthy Pregnant Woman). www.nice.org.uk.
CANADA: Society of Obstetricians and Gynaecologists of Canada.
Clinical Practice Guidelines. Obstetrics. www.sogc.org
WHO: Reproductive Health Library. Pregnancy and Childbirth.
http://apps.who.int/rhl/pregnancy_childbirth/en/
Notes
20