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EvidenceBased Prenatal Care


( C-UK/US) ... Preventing Group B streptococcus (GBS) infection in newborn babies: information for you. ... Kramer MS, Kakuma R. Energy and protein intake in ... – PowerPoint PPT presentation

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Title: EvidenceBased Prenatal Care

Evidence-Based Prenatal Care
  • Carolyn Halley, MD
  • August 2006

  • How strong is the evidence for our prenatal
    standards of care?
  • What areas of prenatal care are controversial?
  • In which areas is there important ongoing

  • Caregiver continuity during the antenatal period
    has been associated with reduced interventions in
    labor and improved maternal satisfaction. (A-UK)
  • Care provided by midwives, family physicians, and
    obstetricians was found to be equally effective,
    although women were slightly more satisfied with
    care from midwives and family physicians. (A-UK)

Number of Visits
  • Women in the US typically attend regular prenatal
    visits, usually 7-14 times per pregnancy.
  • For a woman who is nulliparous with an
    uncomplicated pregnancy, a schedule of ten
    appointments should be adequate. For a woman who
    is parous with an uncomplicated pregnancy, a
    schedule of seven appointments should be
    adequate. (B-UK)

EDC Determination
  • A Cochrane review in 1998 found that U/S before
    24 weeks resulted in earlier detection of
    multiple pregnancies and reduced rates of
    induction of labor for post-term pregnancy.
  • In a 1996 study of over 34,000 pregnancy records,
    EDC based on U/S before 20 weeks instead of
    certain LMP reduced induction rates by 70.

EDC Determination
  • In health systems in which reliable early
    pregnancy U/S is available at an acceptable cost,
    it should be performed routinely and the EDC
    should be revised, to avoid unnecessary induction
    of labour for a mistaken diagnosis of post-term
    pregnancy. (Cochrane 1997)
  • Pregnant women should be offered an early
    ultrasound scan to determine gestational age (in
    lieu of LMP for all cases) and to detect multiple
    pregnancies. (A-UK)

Routine MonitoringUrine Dipstick
  • BP every visit (C-US)
  • Whenever blood pressure is measured, urine
    dipstick should be tested for proteinuria.
  • A meta-analysis published in 2005 showed
    screening for GDM and pre-eclampsia using urine
    dipsticks for glycosuria is ineffective with low
    sensitivities and low PPV.

Routine MonitoringUrine Dipstick
  • Recommendation from this meta-analysis is to
    perform a urinalysis ONLY at the first prenatal
    visit in low-risk women. (B-US).
  • USPSTF advises testing for proteinuria only with
    high BP.
  • The US Institute for Clinical Sx Improvement, and
    Canadian an Australian health groups recommend
    against routine urine testing.
  • ACOG advises that there is no reliable predictive
    test for preeclampsia and is silent on glycosuria.

Routine Monitoring
  • Maternal height and weight should be measured at
    first antenatal visit to determine BMI. (B-US)
  • Measurement of the uterine fundus to assess fetal
    growth at each visit (B-US, A-UK)

Routine monitoring
  • Auscultation of the fetal heart tones after 10
    wks at each visit, to confirm viability only.
    (C-US, D level evidence recommends against
    routine auscultation, except to reassure mother).
  • Routine antenatal pelvic examination does not
    accurately assess gestational age or accurately
    predict preterm birth or CPD and is not
    recommended. (B-UK)

Anticipatory Guidance
  • Breastfeeding is best for most infants. (B-US)
  • Hot tubs and saunas probably should be avoided
    during the first trimester (A-US)
  • Sexual intercourse during pregnancy is not
    associated with adverse outcomes. (B-US)
  • Moderate exercise may be initiated or continued
    (A-UK). Scuba diving and activities with risk of
    fall are not recommended. (C-US)

Anticipatory Guidance
  • Prolonged standing and exposure to certain
    chemicals are associated with pregnancy
    complications. (B-US)
  • Pregnant women should be informed about the
    specific risks of smoking during pregnancy. The
    benefits of quitting at any stage should be
    emphasized. (A-US/UK)

Anticipatory Guidance- Alcohol
  • There is no known safe amount of alcohol
    consumption during pregnancy. Abstinence is
    recommended. (B-US).
  • Excess alcohol has an adverse effect on the
    fetus. Therefore it is suggested that women limit
    alcohol consumption to no more than one standard
    unit per day. (C-UK)

Dietary guidelines
  • Moderate amounts (1-2 cups coffee) of caffeine
    are probably safe. (B-US)
  • Pregnant women should avoid shark, swordfish,
    kind mackeral and tilefish, and tuna steaks and
    should limit intake of other fish (including
    canned tuna) to 2-3 meals per week. (B-US)
  • Soft chese (feta, brie, bleu) should be avoided
  • Lots of other C-level evidence on artificial
    sweeteners, raw eggs, herbal teas, etc.

  • Begin folic acid supplementation at least 1 month
    before conception. (A-US/UK)
  • Be screened for anemia and treated with iron if
    necessary. (B-US/UK). Iron supplementation should
    NOT be offered routinely to all pregnant women.
  • Pregnant women should limit vitamin A intake to 5000 IU/day. (B-US, C-UK)

Infectious Disease
  • Routine screening for active Hep B, syphilis, and
    HIV (A, A, B-US A, B, A-UK)
  • Routine screening (and tx) for asymtomatic
    bacteriuria by urine culture at 12-16 wks.
  • Routine screening for BV is not recommended.
  • All asx pregnant women aged at increased risk should be screened for
    chlamydial infection. (B-US)

Infectious Disease
  • After a significant varicella or zoster contact,
    a susceptible pregnant women (regardless of
    gestational age) should be given VZIG (up to 10
    days after contact). (B-UK)
  • Routine antenatal screening for HSV 1/2
    antibodies is not recommended. (B-UK) Pregnant
    women contracting HSV during pregnancy or those
    with frequent outbreaks should receive acyclovir
    beginning at 36 weeks. (C-UK)

Infectious Disease
  • US standard of care is to test all pregnant women
    for GBS by vaginorectal cx at 35-37 wks and treat
    colonized women with IV abx at labor or 18 hrs
  • This recommendation by CDC and ACOG is based on a
    nonramdomized, pop-based study from 2002.
  • Pregnant women should NOT be offered routine
    antenatal screening for GBS based on insufficient
    evidence. (C-UK) However, women with GBS positive
    urine or with a h/o having a GBS infected infant
    in the past should receive antibiotics. (C-UK)
  • Canadian TF on Preventative Health Care recomends
    universal screening with selective tx of
    colonized women who also have clinic risk factors.

GDM Screening
  • The USPSTF found fair to good evidence that
    screening combined with diet and insulin therapy
    can reduce the rate of fetal macrosomia in women
    with GDM.
  • However, it found insufficient evidence that
    screening for GDM substantially reduces important
    adverse health outcomes for mothers or their
    infants (for example, cesarean delivery, birth
    injury, or neonatal morbidity or mortality).
  • According to the Agency for Healthcare Research
    and Quality the NNS to prevent one brachial
    plexus injury is about 3,300-8,900

GDM Screening
  • The USPSTF concludes that the evidence is
    insufficient to recommend for or against routine
    screening for gestational diabetes.
  • The evidence does not support routine screening
    for GDM and therefore it should not be offered.
  • The National Institute for Child Health and Human
    Development is currently sponsoring an RCT on GDM
    screening involving approximately 2,400 women.

  • Cesarean delivery on maternal request (CDMR)
    compared with planned vaginal delivery (PVD).
    Virtually no studies exist on CDMR, so the
    knowledge base rests chiefly on indirect evidence
    from proxies possessing unique and significant
    limitations. Furthermore, most studies compared
    outcomes by actual routes of delivery, resulting
    in great uncertainty as to their relevance to
    planned routes of delivery. Our comprehensive
    assessment, across many different outcomes,
    suggests that no major differences exist between
    primary CDMR and PVD, but the evidence is too
    weak to conclude definitively that differences
    are completely absent. Given the limited data
    available, we cannot draw definitive conclusions
    about factors that might influence outcomes of
    planned CDMR versus PVD. (USPSTF March 2006)

At term
  • Abdominal palpation should be used to assess
    fetal presentation beginning at 36 weeks.
  • Antenatal perineal massage reduces the likelihood
    of perineal trauma (mainly episiotomies) for
    primips and the reporting of ongoing perineal
    pain for multips. Women should be made aware of
    the likely benefit of perineal massage and
    provided with information on how to massage.
    (Cochrane 2006)

At term
  • Both US and clinical exam are reasonably
    sensitive in predicting birthweights greater than
    4,000 gm in prolonged pregnancy, but they perform
    less well at predicting the more clinically
    relevant weight of greater than 4,500 gm.
    Evidence from one randomized trial shows that
    induction of labor based on estimated fetal
    weight does not improve outcomes for either
    infant or mother. There also is no evidence that
    an antepartum diagnosis of birthweight greater
    than 4,000 grams improves outcomes. (USPSTF March
  • Women who have an uncomplicated singleton breech
    pregnancy at 36 wks gestation should be offered
    external cephalic version (ECV). (A-UK)

At Term
  • Sweeping of the membranes should be offered at
    term to reduce the need for labor induction
    (NNT8). (A-US)
  • Routine sweeping of the membranes at 38 weeks is
    associated with reduced duration of pregnancy,
    reduced frequency of pregnancy continuing beyond
    41 weeks, and increased discomfort. Number needed
    to prevent one induction 8. (Cochrane does not

  • Labor induction is recommended at 41 weeks' to
    reduce perinatal mortality rates. Induction does
    not increase rates of perinatal complications,
    but does not reduce rates of cesarean delivery.
  • Prior to formal induction of labour, women should
    be offered a vaginal examination for membrane
    sweeping. (A-UK)

  • GDM screening
  • US vs. certain LMP for EDC
  • Abstinence from alcohol during pregnancy
  • Routine GBS screening
  • Routine testing for glycosuria and proteinuria
  • Membrane sweeping at term

  • Villar J, Carroli G, Khan-Neelofur D, Piaggio G,
    Gülmezoglu M. Patterns of routine antenatal care
    for low-risk pregnancy. Cochrane Database of
    Systematic Reviews 2001, Issue 4.
  • Royal College of Obstetricians and Gynecologists.
    "Preventing Group B streptococcus (GBS) infection
    in newborn babies information for you." RCOG
  • National Collaborating Centre for Women's and
    Children's Health. Antenatal care routine care
    for the healthy pregnant woman. Accessed online
    January 17, 2005, at http//www.rcog.org.uk/resou
  • Mongelli M, Wilcox M, Gardosi J. Estimating the
    date of confinement ultrasonographic biometry
    versus certain menstrual dates. Am J Obstet
    Gynecol 1996174(1 pt 1) 278-81.
  • Neilson JP. Ultrasound for fetal assessment in
    early pregnancy. Cochrane Database of Systematic
    Reviews 1998, Issue 4.
  • Briscoe, D, et al. Management of Pregnancy Beyond
    40 Weeks' Gestation. American Family Physician.
    May 15, 2005.
  • Boulvain M, Stan C, Irion O. Membrane sweeping
    for induction of labour. Cochrane Database of
    Systematic Reviews 2005, Issue 1.
  • Hodnett ED. Continuity of caregivers for care
    during pregnancy and childbirth. Cochrane
    Database of Systematic Reviews 2000, Issue 1.
  • Neilson JP. Ultrasound for fetal assessment in
    early pregnancy. Cochrane Database of Systematic
    Reviews 1998, Issue 4.

  • Beckmann MM, Garrett AJ. Antenatal perineal
    massage for reducing perineal trauma. Cochrane
    Database of Systematic Reviews 2006, Issue 1.
  • Kramer MS, Kakuma R. Energy and protein intake in
    pregnancy. Cochrane Database of Systematic
    Reviews 2003, Issue 4.
  • Crowley P. Interventions for preventing or
    improving the outcome of delivery at or beyond
    term. Cochrane Database of Systematic Reviews
    1997, Issue 1.
  • Scott D A, Loveman E, McIntyre L, Waugh N.
    Screening for gestational diabetes a systematic
    review and economic evaluation. Health Technology
    Assessment. 20026(11)1-172.
  • Gilson, GJ, et al. Prevention of group B
    streptococcus early-onset neonatal sepsis
    comparison of the Center for Disease Control and
    prevention screening-based protocol to a
    risk-based protocol in infants at greater than 37
    weeks' gestation. J Perinatol. 2000 Dec20(8 Pt
  • American Diabetes Association (ADA). Standards of
    medical care in diabetes. III. Detection and
    diagnosis of GDM. Diabetes Care 2006 Jan
  • Centers for Disease Control and Prevention.
    Prevention of perinatal group B streptococcal
    disease revised guidelines from CDC. MMWR Recomm
    Rep 2002 Aug 1651(RR-11)1-22.
  • National Collaborating Centre for Women's and
    Children's Health. Antenatal care routine care
    for the healthy pregnant woman. London RCOG
    Press 2003 Oct. 286 p.
  • Alto, William, MD. No Need for routine
    glycosuria/proteinuria screen in pregnant women.
    Journal of Family Practice. Vol 54, No 11,
    November 2005
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