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

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VA/DoD Clinical Practice Guideline For Pregnancy Management Table 2. Conditions Requiring Supplemental Care Risk Assessed by Routine Prenatal Care Provider GENERAL CONDITIONS Genetic condition potentially affecting fetus Body Mass Index (BMI < 16.5 or >30) Age < 16 or > 34 Genetic condition affecting patient or spouse OBSTETRIC CONDITIONS (current or historical) Recurrent pregnancy loss Ectopic pregnancy Significant abdominal pain/cramping Vaginal bleeding Second-trimester pregnancy loss Preterm labor (current) or birth (history) Cervical surgery (LEEP, cone biopsy) Uterine abnormality Short ( 36 weeks) Placenta Previa (symptomatic or beyond 28 weeks) Abnormal amniotic fluid: oligo/poly hydramnios Preterm ruptured membranes Fetal growth abnormality (90 %tile) Known or suspected fetal anomaly Multiple gestation Isoimmunization Abnormal prenatal screening result (aneuploidy risk) Abnormal prenatal screening result (ONTD risk) Intrauterine fetal demise Teratogenic exposure including drugs or radiation Placental abruption Prior cesarean section Intrapartum complications GYNECOLOGIC, MEDICAL, SURGICAL CONDITIONS Current need for surgery Bariatric surgery (< 18, > 36 months ago) Diabetes mellitus (DM) – Type 1 or 2 Hematalogic disorders (except mild anemia) Gastrointestinal disorders on medication Chronic hypertension Cardiovascular disease Pulmonary disease including asthma Cancer (current or recent) Neurological disorders including epilepsy Renal, urinary tract disorder Referral/Consult with Advanced Prenatal Care Provider √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Consider Referral/Consult with Advanced Prenatal Care Provider √ √ √ √ √ √ √ Algorithm and Annotations Page - 19
VA/DoD Clinical Practice Guideline For Pregnancy Management Risk Assessed by Routine Prenatal Care Provider Autoimmune disorder including Lupus Antiphospholipid syndrome Hyperlipidemia prior to pregnancy Transplant Abnormal pap smear Breast abnormality Pelvic surgery for infertility or infection Illicit drug, alcohol, or tobacco use Thyroid disorders INFECTIOUS DISEASES Severe pelvic infections Hepatitis Tuberculosis HIV TORCH infection Sexually transmitted disease (STD) PSYCHOSOCIAL CONDITIONS Major depressive disorder (MDD) Domestic violence Referral/Consult with Advanced Prenatal Care Provider To Mental Health if suicidal or moderate or severe MDD √ √ √ √ √ √ √ √ √ To Social Work if unsafe environment Consider Referral/Consult with Advanced Prenatal Care Provider Homeless To Social Service √ √ √ √ √ √ √ √ √ A4. Assessment of Risk Factors for Preterm Birth BACKGROUND Preterm birth is the second leading cause of neonatal mortality in the United States. Although many preterm births are due to the development of obstetric complications, over 70 percent result from spontaneous preterm birth which includes deliveries related to idiopathic preterm labor, preterm rupture of membranes, and cervical insufficiency. Demographic or historical risk factors for spontaneous preterm birth delivery may be discovered at the initial nursing intake or provider visit. Other risk factors develop as a woman’s pregnancy progresses and include certain symptoms or physical examination and imaging findings. Although the prediction and prevention of spontaneous preterm birth remain challenging, continual surveillance for these risk factors may be beneficial as effective therapeutic options are developed. Some risk factors only require annotation in the obstetric record and routine surveillance as indicated in this pregnancy guideline. The identification of other risk factors should prompt increased surveillance in the form of consultation with an advanced prenatal care provider or ancillary testing and imaging studies. To date, no single test or sequence of tests has an optimal sensitivity or predictive value for preterm birth. Fetal fibronectin testing and cervical length measurement by transvaginal ultrasound appear to be useful in the management of some women meeting the criteria for increased surveillance. Most studies have shown that these tests have limited utility when used in the asymptomatic woman at low risk for preterm delivery. Importantly, modalities such as salivary estriol levels, bacterial vaginosis screening and home uterine activity monitoring are generally not effective at predicting preterm birth regardless of risk status. Algorithm and Annotations Page - 20
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