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

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VA/DoD Clinical Practice Guideline For Pregnancy Management • Late entry counseling. This counseling should be provided to women presenting for prenatal care when the gestational age of her pregnancy limits options for screening strategies or diagnostic testing. The counseling should be based on the individual circumstances including the gestational age and patient desires. EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 All women, regardless of age, should be offered aneuploidy screening 2 When discussing options with patients, providers should furnish information on detection and false positive rates, advantages and disadvantages of each testing method ACOG, 2007 III Fair B ACOG, 2007 III Fair B 3 Unique benefits with each type of intervention: individual counseling, group counseling sessions, and use of decision aids and audiovisual presentation 5 First-trimester screening can lead to a diagnosis of fetal aneuploidy much earlier 6 Measurement of nuchal translucency alone is less effective for first-trimester screening than is the combined test (nuchal translucency measurement and biochemical markers) Hunter et al., 2005 Fries et al., 2005 ACOG, 2007 Malone et al., 2003, 2005 Wapner et al., 2003 Wald et al., 2003 Nicolaides et al., 2004 Snijders et al., 2002 I Fair B I Good A IIb Fair B 7 Patients undergoing first-trimester screening for aneuploidy should be offered maternal serum alpha fetoprotein (MSAFP) in the second trimester to screen for open neural tube defects Lennon et al., 1999 Nicolaides et al., 1992 II Fair B LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) Interventions Page - 75
VA/DoD Clinical Practice Guideline For Pregnancy Management Visits During Weeks: 1627 I 37. Obstetric Ultrasound: Week 1620 BACKGROUND Ultrasound is commonly performed for a host of reasons to include earlier detection of severe anomalies, confirmation of dating, general assessment of fetal well-being, and maternal reassurance. It is not possible to completely separate aneuploidy screening from the above when ultrasounds are performed. Fetal assessment by a comprehensive sonographic survey has been proven to be a useful means of ascertaining fetal health and establishing an accurate gestational age in, pregnant women. Women with specific risk factors, or who develop high-risk conditions that may complicate the pregnancy, require additional surveillance including ultrasound(s) to assist in decision making. None-the-less, the routine use of screening ultrasound in low risk women has not been conclusively demonstrated to improve long-term outcome in the offspring of these women. Thus, from a cost effectiveness standpoint, the routine use of screening ultrasound in well-dated pregnancies remains controversial. A single screening ultrasound examination at 18-20 weeks for all pregnant women who desire the examination after having been counseled regarding the limitations and safety of the exam is supported by ACOG. ACTION ITEM Second trimester scanning should be recommended and available to women considering an invasive test on the basis of age, or other risk factors, when the absence of soft markers may lower the estimated risk and assist decisionmaking. RECOMMENDATIONS 1. Recommend counseling and educating all pregnant women prior to scheduling sonographic studies about the potential benefits, limitations, and safety of prenatal ultrasound. Documentation of education and counseling is recommended; however, written informed consent is not deemed necessary. [C] 2. A complete obstetric sonographic examination should be recommended and available to women considering an invasive test on the basis of age, or other risk factors, when a more accurate gestational age is required for decision-making regarding medical or antenatal routine care interventions, or for predicting actual date of delivery [A] 3. A complete obstetric sonographic examination should be recommended and available to women or who are at increased risk for a songraphically detectable maternal or fetal abnormality where an intervention may improve the outcome (See table for list of indications) [A]. 4. There is insufficient evidence to recommend for or against complete obstetric sonographic examination in the second trimester to all low-risk asymptomatic consenting pregnant women [I] 5. All complete obstetric sonographic studies hold be performed and interpreted by qualified healthcare providers. [A] (See Standard for Performance of Antepartum Obstetrical Ultrasound Examination at: http://www.aium.org/publications/clinical/obstetric.pdf) Interventions Page - 76
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Management of pregnancy - VA/DoD Clinical Practice Guidelines ...

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