Management of pregnancy - VA/DoD Clinical Practice Guidelines ...

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VA/DoD Clinical Practice Guideline For Pregnancy Management DISCUSSION Several studies have shown that pregnant women with short cervices detected via routine second-trimester transvaginal ultrasound screening have a greater risk of preterm delivery than do pregnant women without short cervices. The predictive value varies depending on the study population and cervical length cut-off, but in general, short cervical lengths are quite specific, but not sensitive, at predicting preterm delivery. Therefore, a negative finding does not substantially decrease a pregnant woman’s risk of preterm delivery, whereas a positive finding does increase the risk. In a routine, low-risk population, one-half of pregnant women with the shortest cervical lengths (
VA/DoD Clinical Practice Guideline For Pregnancy Management optimal timing or interval of this testing is not known, though this has traditionally been performed at 24 to 28 weeks. Pregnant women at risk for sexually transmitted disease through high-risk sexual behavior may benefit from repeat testing. However, no data exists to support improved outcomes for mothers or infants in those who are screened. EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 Repeat antibody screening (not recommended) 2 Repeat anemia and syphilis screening (not recommended) Davis & Abbott, 1986 II-2 Fair D Working Group Consensus III Poor D 3 Repeat anemia and syphilis screening Working Group Consensus III Poor C for high-risk pregnant women LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) I 65. Routine Screening for Hypothyroidism: Not Recommended BACKGROUND Recent publications have drawn attention to the role of thyroid hormone status of the mother on the future neuropsychological development of the child. Screening all pregnant women for thyroid hormone status has been suggested. To date, however, there are no evidence-based studies to provide meaningful and clinically relevant data to guide the practitioner. RECOMMENDATIONS 1. 2. Recommend against routine screening for thyroid hormone status of the mother. [D] Recommend ensuring adequate iodine intake during pregnancy for pregnant women in areas of the country with questionable levels of dietary iodine. [C] DISCUSSION First-trimester hypothyroxinemia (a low for gestational age circulating maternal free T4, whether or not thyroid stimulating hormone [TSH] is increased) may pose an increased risk for poor neuropsychological development of the fetus. This would be a consequence of decreased availability of maternal T4 to the developing brain, its only source of thyroid hormone during the first trimester. The mother is the sole source of thyroid hormones until about 12 weeks’ gestation, when the fetal gland becomes active. Also, in pregnancy normal TSH may occur when free T4 levels are low (normal maternal T3 concentrations may prevent an increase in TSH). Hypothyroidism or subclinical hypothyroidism during pregnancy often stems from autoimmune disease (Hashimoto’s) but may result from mild iodine deficiency. The presence of thyroid antibodies with a normal TSH may predict those pregnant women who are likely to progress to frank hypothyroidism, which may necessitate closer monitoring of the mother. The question of relevance is whether low maternal free T4 levels, which are still within the range generally accepted as having no adverse effects for the mother, might interfere with normal neurodevelopment of the offspring. Additionally, when subclinical hypothyroidism or evidence of possible autoimmune thyroid disease (i.e., high anti – thyroid peroxidase antibodies) is present, the clinical relevance of this on maternal pregnancy and outcome is currently unclear. There is insufficient evidence that screening and early treatment of pregnant women with subclinical hypothyroidism or maternal hypothyroxinemia improves subsequent neonatal outcome. Routine screening, therefore, cannot be recommended at this time. Interventions Page - 108
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