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

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VA/DoD Clinical Practice Guideline For Pregnancy Management EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 Perform a routine screening for GDM at 24 to 28 weeks with a random onehour 50-gram glucose challenge test Danilenko-Dixon et al., 1999 Griffin et al., 2000 Williams et al., 1999 II-2 Fair B 2 Early screening of selected pregnant women with risk factors for GDM Working Group Consensus III Poor I 3 Method of screening is a random onehour 50-gram glucose challenge ACOG, 2001 Naylor et al., 1997 II-1 II-3 Good B 4 All pregnant women with a one-hour positive test require a three-hour GTT ACOG, 2001 III Fair B 5 Acceptable sets of threshold values for the three-hour 100 gram glucose challenge ACOG, 2001 ADA, 2002 II-3 Fair B 6 One abnormal value for a three-hour GTT warrants consideration of dietary management and glucose monitoring, or a repeat three-hour GTT approximately one month after the initial test ACOG, 2001 Langer et al., 1987 Lindsay et al., 1989 III II-2 II-2 Fair C 7 A high-carbohydrate diet before oral GTT is not necessary in normally nourished pregnant women Buhling et al., 2004 Crowe et al., 2000 Entrekin et al., 1998 II-1 Poor C 8 Patients with history of gastric bypass Burt, 2005 III Poor C may not tolerate the 50-gram GTT; alternative is a fasting and two-hour postprandial finger sticks LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) I 41. Iron Supplement: Week 28 BACKGROUND Iron supplementation in pregnancy is commonly practiced and generally expected by women in the United States. This tradition is based on the assumption that women have increased nutritional requirements during pregnancy that cannot be met by diet alone. RECOMMENDATIONS 1. There is insufficient evidence to recommend for or against routinely supplementing iron for all pregnant women. [I] 2. Women exhibiting signs or symptoms of anemia at any time during their pregnancy should be evaluated upon presentation. [I] 3. Obtain a serum ferritin if iron deficiency anemia is suspected. Recommend supplementing with at least 50 mg elemental iron (325 mg ferrous sulfate) twice a day (bid) in all pregnant women diagnosed with iron deficiency anemia (abnormal ferritin). [B] Interventions Page - 85
VA/DoD Clinical Practice Guideline For Pregnancy Management DISCUSSION Published trials confirmed the improvements in hematological status but did not evaluate other clinical outcomes (Milman et al., 1999; O’Brien et al., 1999; Pena-Rosas & Viteri, 2006). A Cochrane systematic review (Mahomed, 2001) found no evidence to recommend for or against routine iron supplementation. There was a paucity of information related to clinically relevant maternal and infant outcomes (Pena-Rosas & Viteri, 2006). Another Cochrane systematic review found insufficient data assessing clinical maternal and neonatal effects of iron administration in women with iron deficiency anemia (Reveiz et al., 2007). Again, of concern was a lack of trials with clinically relevant outcomes and paucity of data on adverse effects. EVIDENCE TABLE Recommendations Sources of Evidence LE QE SR 1 Routine iron supplementation Pena-Rosas & Viteri, 2006 Ziaei et al., 2007 II-3 I Poor I 2 Selective iron supplementation Hemminki & Rimpela, 1991 I Good B Reveiz et al., 2007 LE = Level of Evidence; QE = Quality of Evidence; SR = Strength of Recommendation (See Appendix A) I 42. AntiD Prophylaxis for RhNegative Pregnant Women: Week 28 BACKGROUND The incidence of Rh incompatibility varies by race and ethnicity. Approximately 15 percent of whites are Rh negative, compared with five to eight percent of African Americans, and one to two percent of Asians and Native Americans. Among whites, an Rh negative woman has an approximate 85 percent chance of mating with an Rh positive man, 60 percent of whom are heterozygous and 40 percent of whom are homozygous at the D locus. Pregnant women who have had D antigen isoimmunization in a previous pregnancy have an increased risk for development of fetal anemia and hydrops in future pregnancies. Since the introduction of anti-D (Rhogam) immune globulin injections during and after pregnancy in women who are D-antigen negative, the incidence of isoimmunization has fallen from 10 cases to 1.3 cases/1,000 live births. RECOMMENDATIONS 1. Recommend determination of paternal erythrocyte antigen status for screen-positive women. [I] 2. Recommend administering anti-D prophylaxis to all unsensitized D-negative pregnant women. [B] 3. 4. Recommend using either 300 mcg of anti-D immunoglobulin at 28 weeks or 100 mcg of anti-Dimmunoglobulin at 28 and 34 weeks’ gestation. [I] Pregnant women who have had isoimmunization in a previous pregnancy or who are screened positive for antibody screen should be referred to a Maternal Fetal Medicine specialist for care. [A] DISCUSSION The term “isoimmunization” refers to the detection of maternal antibodies to red blood cell antigens. All trials of antenatal anti-D prophylaxis included routine postpartum anti-D prophylaxis for women with Rhpositive infants when clinically indicated. A Cochrane review of two fair-quality RCTs shows a decrease in isoimmunization rates of Rh-negative women after antenatal anti-D prophylaxis, though only at a dose of 100 mcg at 28 and 34 weeks’ gestational age (Crowther, 2001). Interventions Page - 86
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