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

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VA/DoD Clinical Practice Guideline For Pregnancy Management 3. 4. Td booster should be provided if indicated. There are no contraindications other than a previous severe reaction to Td vaccination, such as anaphylaxis, generalized uriticaria, or angioedema. [A] If the pregnant woman is an immigrant and it is unclear that she ever received the primary vaccination series, she should be given a primary series with an initial dose, a second dose a month later, and a third dose 12 months later. [B] DISCUSSION Effective antibody response is 95 to 100 percent in healthy adults after primary vaccination series. Immunity wanes over the years and the precise duration of immunity is unknown for specific individuals, but generally lasts at least a decade for small inoculum of tetanus encountered in a small or minor wound. For any other wound, it is recommended that a tetanus booster be administered unless the patient has received a Td booster within the previous five years. Neonates receive passive immunization from maternal antibodies until their immune system is adequate to provide an antibody response to neonatal vaccinations. EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 Screening for Td booster status at the first prenatal visit USPSTF, 1996 II-1 Good A 2 If no documentation of Td booster within the last 10 years, provide Td booster; there are no contraindications other than documented allergies to administration of Td during pregnancy Fingar et al., 1998 ICSI, 2001 USPSTF, 1996 II-1 Good A 3 Pregnant women deemed unlikely to have received initial three-dose vaccination (immigrants from underdeveloped countries) should receive an initial three dose series Fingar et al., 1998 ICSI, 2001 USPSTF, 1996 II-2 Fair B LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) I 18. Screening for Anemia: Weeks 68 BACKGROUND Anemia occurs in two to four percent of pregnant women. It is defined as a hemoglobin or hematocrit concentration less than the five percentile of a healthy pregnant population and varies during the trimesters of pregnancy and in African versus non-African populations. Non-African women with a hematocrit less than 33, 32 and 33 percent in the first, second and third trimesters, respectively, are anemic. The threshold for anemia in the African-American population is two percent lower. Severe anemia, defined as a hemoglobin < 6 gm/dL is associated with adverse pregnancy outcomes due to inadequate fetal oxygenation. Iron deficiency and acute blood loss are the most common causes of anemia. Anemia can be categorized by the size of the red blood cell (microcytic, normocytic and macrocytic), the mechanism of the anemia, or by whether the anemia is acquired or inherited. Certain ethnic groups are at increased risk for inheritable causes of anemia and should be screened for such (see Appendix C - Screening for Hemoglobinopathies). Iron deficiency anemia is usually microcytic (Mean Corpuscular Volume
VA/DoD Clinical Practice Guideline For Pregnancy Management RECOMMENDATIONS 1. All pregnant women should be screened for anemia during pregnancy with a hematocrit or hemoglobin measurement in the first and third trimester. [C] 2. Pregnant women with anemia should be further evaluated to define the cause of the anemia and given nutrient supplementation if deficient (e.g. iron, B12 or Folate). [C] 3. 4. Red blood cell transfusion should be considered for pregnant women with severe anemia. [C] Iron sucrose transfusion should be considered for pregnant women with iron deficiency anemia who fail to respond to oral iron supplementation after eliminating modifiable causes of malabsorption. [C] EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 All pregnant women should be screened for anemia during pregnancy with a hematocrit or hemoglobin measurement in the first and third trimester 2 Pregnant women with anemia should be further evaluated to define the cause of the anemia and given nutrient supplementation if deficient (e.g. iron, B12 or Folate) ACOG, 2008 #95 CDC, 1998 ACOG, 2008 #95 Institute of Medicine, 1993 Reveiz et al., 2007 III Fair C II, III Fair C 3 Red blood cell transfusion should be considered for pregnant women with severe anemia ACOG, 2008 #95 II Fair C 4 Iron sucrose transfusion should be considered for pregnant women with iron deficiency anemia who fail to respond to oral iron supplementation after eliminating modifiable causes of malabsorption ACOG, 2008 #95 Faich & Strobos, 1999 Bhandal & Russell, 2006 III Fair C LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) I 19. Screening for Hemoglobinopathies: Weeks 68 BACKGROUND The hemoglobinopathies are a heterogeneous group of single-gene disorders that includes the structural hemoglobin variants such as sickle cell disease and thalassemia. More than 270 million people worldwide are heterozygous carriers of hereditary disorders of hemoglobin, and at least 300,000 affected homozygotes or compound heterozygotes are born each year. Sickle cell disease and the thalassemias are discussed below. RECOMMENDATIONS 1. Carrier screening should be offered to individuals of African, Southeast Asian, and Mediterranean descent. [A] 2. A complete blood count and hemoglobin electrophoresis are the recommended tests to screen for hemoglobinopathies. [B] Interventions Page - 46
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