Transcript Update on Prenatal Care for Family Physicians

FIRST TRIMESTER CARE
2016
OBJECTIVES
To be able to confirm and accurately date
pregnancies
 To be able to provide early pregnancy care as
family physicians
 To be able to provide early pregnancy counselling
 To be able to identify and manage early
pregnancy complications

CASE #1 - MARGARET
31 year old G2T0P0A1L0 comes in
 She is certain that her LMP was 8 weeks ago
 Feels tired and nauseated but has not had any
vomiting
 Was trying to get pregnant and is happy
 Pulls out of her purse a list of questions


What questions do you have for her?
DATING THE PREGNANCY
very important, must be done accurately at the
first visit
 has implications for prenatal screening tests
 important to avoid inadvertent labeling of postdates at the end of pregnancy or size discrepancy


See SOGC Clinical Practice Guideline – Determination of
Gestational Age by Ultrasound, No. 303, Feb. 2014
LMP most accurate if woman is certain and has
regular menses
 early ultrasound (prior to 8-9 weeks) accurate
within a few days1
 11-14 week ultrasound is sufficient to
confirm dates and do nuchal translucency
(NT) at the same time


Does Margaret need an US now?
COULD THIS PREGNANCY BE AT RISK?

Maternal factors:
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Pre-existing medical conditions: esp cardiac
disease, diabetes, Hypertension, renal disease,
anemia, thyroid disease
Obesity, low body weight
Grand Multipara (> 5 pregnancies)
Substance abuse, smoking, domestic abuse, $,
housing, severe mental health issues
Infectious diseases: gc, chlam, HIV, syphilis, Hep
B, TB.
 Also if no hx varicella, rubella
Occupational exposure: job specific (eg radiation),
physical requirements (eg standing, shift work),
infectious (eg. parvovirus B19 and teachers)
COULD THIS PREGNANCY BE AT RISK?
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Inherited disorders: eg. thalassemia
Anatomical: previous uterine surgery (other
than prev C/S), cervical incompetence (? Past
LEEP)
History of Genetic Disease (developmental
delay, congenital anamalies, chromosomal
disorders, genetic disorders) in family (both
parents)
History of prior stillbirth, neonatal death,
premature delivery
AMA (Advanced maternal age) >35yo
IVF pregnancy
Multiple gestation
Rh immunization
PRENATAL GENETIC SCREENING
Rapidly expanding field
 Tests are being performed earlier, often before
referral to other care providers, so they need to
be brought up at first visits
 Important role for family physician


When should you start this conversation with
Margaret? Where can she get more information?
Which women require special management?
GENETIC SCREENING

SOGC Clinical Practice Guideline “Prenatal Screening
for Fetal Aneuploidy in Singleton Pregnancies ” - No
261,July 2011
“All pregnant women, regardless of age, should be
offered prenatal screening for the most common
clinically significant fetal aneuploidies in addition to a
second trimester ultrasound for dating, assessment of
fetal anatomy, and detection of multiples”
 Age of higher risk raised to 40, but most anomalies
occur in young or “low risk” women
 Important legal implications

GENETIC SCREENING
Screens for Down Syndrome, Trisomy 18 and Open
Neural Tube Defects
 IPS and MSS (quad) offered at CHEO
 Excellent “Reference Guide for Health Care Providers”
from Mount Sinai Hospital Family Medicine Genetics
department2
 genetic screening is done earlier and tests have fewer
false positives, especially with accurate dates—onus on
fam doc’s

2. http://www.mountsinai.on.ca/care/family-medicine-genetics-program/prenatal
TYPES OF SCREENING: NONINVASIVE
IPS-1 (Integrated Prenatal
Screen):
11-14wks:
U/S: Measures Nuchal
Translucency (Subcutaneous
layer of fluid behind the fetal
neck and lower cranium).
• Detection rate 69-75% for
Down Syndrome (false + 58.1%).
• Also associated with other
abnormalities esp cardiac so if
abnormal may need level 2 US
IPS – 1
Nuchal translucency + PAPP-A:
Pregnancy Associated Plasma
Protein. Levels are lower in
pregnancies affected with Down
Syndrome. Blood test.
IPS-2 (Integrated Prenatal Screen):


15-20+6wks (ideally at 15+3wks) blood test:
 Free B-hCG: levels are higher in pregnancies
affected with Down Syndrome (avg twice as high).
 AFP: Alpha fetoprotein. fetal specific globulin,
synthesized by the fetal yolk sac, gastrointestinal
tract, and liver. The function of AFP is unknown.
Mainly used to detect open neural tube defects, will
be elevated if positive.
 uE3: Unconjugated estriol. Hormone made by the
placenta. Levels are lower in pregnancies affected
with Down Syndrome and Trisomy 18.
85-90% Detection rate, 2-4% False Positive Rate
TYPES OF SCREENING: NONINVASIVE
Maternal Serum Screening/MSS:
 2nd trimester (15-20+6wks): for those
who miss the window for IPS

Blood test

AFP (↑), hCG (↑), uE3 (↓)
71% detection rate, 7% false positive
rate

DOWN SYNDROME
Trisomy 21
 1 in 800 risk
and increases
with age
 Intellectual
disability,
characteristic
facial
appearance,
hypotonia,
other
congenital
defects (heart,
intestinal)

Mother’ Chance of Chance of any
s age
Down
chromosome
(years) syndrome condition including
trisomy 18, Down
Syndrome and
others
20
1 in 1,650 1 in 530
25
1 in 1,250 1 in 480
30
1 in 950
1 in 390
35
1 in 385
1 in 180
40
1 in 100
1 in 65
45
1 in 30
1 in 19
Reference Guide for Health Providers. Prenatal Screening tests for the detection of: Down Syndrome,
Trisomy 18 and Open Neural Tube Defects. The Genetics Education Project, 2007.
GENETIC SCREENING
o
If patient decides to have genetic screening,
make sure to give:
Req for 12-week U/S (with IPS checked off): certified
facilities only
 2 lab req’s—one for IPS #1 and another for IPS #2
 2 copies of CHEO form, properly filled out, signed
 Counselling about genetic screening


Patient makes apt for U/S and goes for blood
work the same day (if U/S shows viable fetus
between 11 and 14 weeks) and a second blood
test 3-4 weeks later
NIPT
Non-invasive prenatal testing
 Cell-free fetal DNA from maternal serum
 Available very early in preg
 As a screen or as second tier for + IPS
 Usually self pay, appx $900
 Covered by OHIP in certain situations eg. + IPS,
maternal age > 40 yrs
 No risk of fetal loss


SOGC Committee Opinion – Current Status in Non-Invasive
Prenatal Detection of Down Syndrome, Trisomy 18, and Trisomy
13 Using Cell-Free DNA in Maternal Plasma, No. 287, Feb. 2013
TYPES OF SCREENING:
INVASIVE
Amniocentesis: 15-17wks (ideally, can be up to
22wks)
 Sample taken from amniotic fluid, 0.25%
miscarriage rate.
CASE #2 - NAHID
31 year-old multip
 Recently arrived from Afghanistan
 She speaks no English but her husband does
 EGA is approximately16 weeks
 She has had 2 previous miscarriages, 1 stillbirth
and has 1 live child


What other information do you need? How would
you manage this pregnancy?
SPECIALIZED PRENATAL SCREENING
Cystic fibrosis screening for those with family
history
 Specific “panels” available for people from specific
ethnic groups, such as Ashkenazi Jews, Lac St.Jean region
 Women with history of previous fetus/child with
birth defect can be offered additional testing


If in doubt, refer to Genetics at CHEO
ROUTINE BLOOD TESTS TO ORDER
May be better to wait until 8-9 weeks GA when
risk of miscarriage has decreased
 11-12 weeks if patient decides to do IPS
 CBC, blood type and screen
 urine for C&S, STI testing on everyone
 Rubella, HBsAg, VDRL, HIV are all on the Public
Health requisition
 ? TSH

BLOOD TESTS TO CONSIDER
Hep C (high risk or from endemic area)
 sickle cell screen/Hb electrophoresis for ethnic
groups at risk
 blood sugar/HbA1c/T1 50 g GCT if obese or other
risk factors for gestational diabetes

Ask re. history of varicella—test if history
negative or uncertain
 Parvovirus titre in those who work with children
or health-care workers
 Toxo titre not routine, as per SOGC

PELVIC EXAM
Consider pelvic exam in early pregnancy
 Bimanual exam and inspection of genitalia may
be important
 Pap if indicated
 Cervical swabs or urine for GC/chlamydia
 Vaginal swab not indicated, unless discharge or
odour

Routine screening for bacterial vaginosis is not
indicated
 Testing can be done if risk for preterm labour
 Asymptomatic bacterial vaginosis does not need to be
treated

Screening and Management of Bacterial Vaginosis in Pregnancy, SOGC Clinical Practice Guideline, No.
211, Aug. 2008
BREAST EXAM
Important for early discussion about
breastfeeding
 Ask about concerns
 Ask about breast changes
 Ask about breast surgery
 Examine breasts for abnormalies eg. hypoplasia
 Look for variants of normal that can cause
challenges for breastfeeding eg. inverted or flat
nipples, very large breasts

CASE #3 - ANGELA
30 year-old primip
 EGA=11 weeks
 Exhausted, anorexic, vomiting 4-5 times per day

What else do you need to know?
 What advice do you give her?

NAUSEA AND VOMITING OF PREGNANCY/NVP
80% of pregnant women, with hyperemesis
gravidarum in 0.5-1.0% of pregnancies
 NVP may significantly affect quality of life
 Many women and doctors reluctant to treat
 Evidence-based updated treatment algorithm
from Motherisk Dec. 2007
 Non-medical management includes dietary
changes, acupuncture, acupressure, and
ginger – see motherisk


Diclectin seems to be safe and effective
PRENATAL NUTRITION - ISSUES
Folic acid and prenatal multivitamin (PNV)
 Vitamin D
 Health Canada recommends 16-20 mg of iron
daily
 Avoidance of certain foods


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Weight gain – see Health Canada guidelines
Consider dietitian – obesity, vegetarian/vegan, hx
of eating disorder, hx gastric bypass etc.
FOLIC ACID
To produce and maintain new cells
 For rapid cell division and growth
 To prevent NTDs and other congenital anomalies

Water-soluble
 Found in fortified grains, spinach, lentils, chick peas,
asparagus, broccoli, peas, brussels sprouts, corn, and
oranges

FOLIC ACID SUPPLEMENTATION
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

Decreased NTDs, heart defects, urinary tract
anomalies, oral facial clefts, limb defects and
pyloric stenosis
~50% all birth defects can be prevented
with adequate folic acid
When does the neural tube close?
NEURAL TUBE DEFECTS
Failed neural tube closure at upper or lower end
 Multi-factorial
 3-4th week after conception (days 26-28)
 Decreased with folic acid (10/10,000 in 1991 vs.
5.8/10,000 in 1999)
 Decrease in NTD’s may be due to folic acid
supplementation, fortification of food, as well as
increased prenatal screening and pregnancy
termination

WALD ET AL, LANCET 2001
Typical western serum folate 0.2 mg/day would reduce
NTDs by ~20%
 0.4 mg/day expected to reduce NTDs by ~36%
 1 mg/day by ~57%
 5 mg/day by ~85%
 Preventive effect greater in women with low serum
folate

OPTION A – FOLIC ACID
No personal risks, planned preg, good diet, supplement
2-3 months before conception and through preg and
puerperium
 Dose is 0.4-1.0 mg (II-2-A)

OPTION B – FOLIC ACID
Increased risk eg. epilepsy, obesity, family history,
high-risk ethnic group
 Daily supplement of 5 mg 3 months before conception
until 12 weeks
 12 weeks until puerperium continue with 0.4 to 1.0 mg
(II-2-A)

OPTION C – FOLIC ACID
Poor compliance, variable diet, inconsistent birth
control, possible teratogenic substance use
 5 mg folate and multivit (III-B)
 Covered on ODB

VITAMIN D SUPPLEMENTATION
Statement from CPS 2007
 Nil from Health Canada, SOGC
 Maternal vit D status during pregnancy and lactation
may influence child health eg. caries, bone density,
asthma, type 1 diabetes (II-2)
 Requirement seems to vary with weight and BMI

WHAT’S THE DOSE?
Health Canada : 200 IU/day
 Prenatal vits : 400 IU/day
 Maternal dose affects mother and breastmilk
 Postpartum - 4000 IU/day maintained maternal
sufficiency and raised breast milk such that no other
supplement was needed for infant (II-1)

WEIGHT GAIN
Health Canada Guidelines 2007
 Inadequate weight gain associated with low birth
weight baby
 XS weight gain associated with high birth weight ie. >
4000 g
 Recommendations based on pre-pregnancy BMI

GUIDELINES FOR GESTATIONAL WEIGHT
GAIN
BMI < 20
12-5 – 18.0 kg (28-40 lb)
 BMI 20 – 27
11.5 – 16.6 kg (25-35 lb)
 BMI > 27
7.0 - 11.5 kg (15-25 lb)
 Women of short stature to aim for the lower end of
weight gain range

FOODS TO AVOID
Listeria is major concern in terms of food-borne
illness in pregnant women
 Caffeine-intake is common concern of pregnant
women
 Fish is recommended in moderation (150 grams
per week) with focus on cooked fish with low
levels of mercury4 and variety of fish
 Food hygiene re. washing fruits/vegs, avoid
unpasteurized daily and raw meat/seafood

CASE #4 - MATILDA
29 year-old primip
 CIDA field officer and marathon runner
 EGA 10 weeks
 Will be placed in Sudan for 1 month

She is wondering if she can continue running.
 What are your questions? What are your
concerns?
 Does her travel put her pregnancy at risk?

EXERCISE IN PREGNANCY
Generally safe and likely beneficial for low risk preg
 Possible benefits: reduced incidence of gestational
diabetes and PIH, promotion of appropriate weight
gain, facilitation of labor
 www.csep.ca is a good website, PARMed-X forms can
be down-loaded
 SOGC considers exercise in pregnancy a level B
recommendation
 amount and intensity of exercise depends on prepregnancy level of fitness
 Many gyms and rec centres now offer prenatal fitness
classes at reasonable cost
 exercise with risk of trauma should be avoided

EXPOSURES IN PREGNANCY
common concern of pregnant patients and partners
 rapidly expanding and ever-changing field
 Motherisk is accessible, helpful, and provides great
information (www.motherisk.org)
 Vaccines, foods, medications, household chemicals, Xrays

VACCINATION IN PREGNANCY
women of child-bearing age should be asked
about possibility of pregnancy before being given
a vaccine
 Generally live or live-attenuated virus vaccines
are avoided in pregnancy, risk is mostly
theoretical
 Inactivated virus vaccines, bacterial vaccines and
toxoids can be used safely in pregnancy

Immunization in Pregnancy, SOGC Clinical Practice Guideline, No.
236, Nov. 2009
INFLUENZA IN PREGNANCY
Morbidity of influenza increases in 3rd trimester
 Pregnant women with co-morbidities (eg.
asthma) at risk of complications at any stage of
pregnancy
 Flu vaccine recommended for pregnant women
 Flu vaccine safe in pregnancy


Tamiflu also considered safe in pregnancy and
while breastfeeding
TRAVEL
Air-travel generally considered safe
 Airlines have their own rules—different for NorthAmerican and other destinations
 Remind patients of travel insurance—can cover
patient but not unborn child
 Vaccinations need to be considered
 Note stating EDD may be needed

CHOICE OF MATERNITY CARE PROVIDER AND
SETTING OF BIRTH
Family physician vs. OB/GYN vs. midwife vs.
shared care
 Continuity of care with family doc only – mom
and baby
 Midwife is only provider who can offer homebirth,
but can also attend hospital births
 Call-groups
 Preference for female care providers?

SOCIAL SITUATION
Unplanned vs. unwanted pregnancies
 Spousal abuse increases in pregnancy
 Many women experience problems at work during
pregnancy
 Substance use:
http://dfcm.utoronto.ca/research/prima/Home.html
 ALPHA forms are validated assessment tools

CASE #5 - MADONNA
28 yo G3T1P0A1L0
 EGA = 8+3
 Calls clinic with some vaginal bleeding, told to
come into clinic this afternoon

What do you need to know?
 Is a physical exam necessary?
 Which investigations would you order?

T1 BLEEDING

Commonly seen in family doctor’s office
History and physical exam
 Investigations
 Follow-up
 Support/counselling


Ultrasound Evaluation of First Trimester Pregnancy
Complications, SOGC Clinical Practice Guidelines, No. 161,
June2005
EPIDEMIOLOGY
Vaginal bleeding or spotting is very common in
early pregnancy (25% or more)
 Approximately 50% of those woman who have
bleeding will miscarry
 Pregnancy loss more likely if bleeding is heavy
and less likely if an US already showed viable
pregnancy

DIFFERENTIAL DIAGNOSIS
Implantation bleed
 Early pregnancy loss:

anembryonic gestation (blighted ovum)
 abortion (complete, missed, incomplete, inevitable,
threatened, septic)

Ectopic pregnancy
 Gestational trophoblastic disease/molar preg
 Subchorionic hemorrhage
 Cervical/vaginal origin ie. Not from the uterus

TYPES OF EARLY PREGNANCY LOSS
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Anembryonic gestation (a.k.a Blighted ovum)
 gestational sac develops without embryonic structures
Complete spontaneous Abortion
 all products of conception have passed
Embryonic or fetal demise (a.k.a. missed abortion)
 pregnancy loss after the development of embryo of fetus, cervix
closed, no bleeding, products of conception still in utero
Incomplete abortion
 some, but not all, of the products of conception have passed
Inevitable abortion
 dilated cervix, passage of products not yet occurred,
miscarriage is unavoidable, usually in setting of vaginal
bleeding
Threatened abortion
 bleeding <20 weeks GA with closed cervix, pregnancy viable at
time of presentation and may or may not miscarry
ASSESSMENT: HISTORY
Maternal age - SA increases with increased mat age
 LMP and gestational age
 Details about bleeding
 Abdominal pain, cramping, shoulder pain
 Presence/absence/loss of symptoms of pregnancy
 Symptoms of urinary tract infection

ASSESSMENT: HISTORY
Past medical history with risk factors for ectopic
pregnancy (tubal surgery/disease, previous ectopic,
infertility, PID, STI’s)
 chronic disease that increases risk of early pregnancy
loss (antiphospholipid antibody syndrome, PCOS,
thyroid disease, uncontrolled DM)
 infection (HSV, VDRL, toxoplasmosis)

ASSESSMENT: HISTORY
previous early pregnancy loss (3 or more is
considered “recurrent pregnancy loss”)
 Meds: methotrexate, itraconazole, NSAIDS, and
retinoids increase risk for early pregnancy loss
 Social: smoking, alcohol, cocaine
 Psychological: how is the patient coping,
work/home environment

ASSESSMENT: PHYSICAL EXAM
Vital signs and hemodynamic stability
 Abdominal exam:

pain
 Fetal heart audible?


Pelvic exam:
speculum exam to visualize cervix for source of bleeding,
signs of inflammation or passage of products of conception
 Bimanual for masses, uterine size, pain in adnexae or
cervical motion tenderness

INVESTIGATIONS
Swabs for GC/chlamydia if you have done a
speculum exam
 Urinalysis/culture if suspicious for UTI
 Blood work:

CBC
 Blood type and screen
 B-hcG level
 progesterone


Trans-vaginal pelvic ultrasound
INVESTIGATIONS: B-HCG
Absolute value often is not very useful
 May be helpful if done serially (at the same lab as
values can vary)
 Be careful with your interpretation as there is wide
variation between values

From conception to 8 weeks: doubling q 1.94 days
 From 8-10 weeks: doubling q 4.75 days
 From 10-14 weeks: peak at approx. 100,000
mIU/ml then decline to 20,000

INVESTIGATIONS: B-HCG
Time from conception
Level of bHCG (mIU/ml)
1-2 weeks
40-300
3-4 weeks
500-6000
1-2 months
5000-200,000
2-3 months
10,000-100,000
2nd trimester
3000-50,000
3rd trimester
1000-50,000
Non-pregnant
<5
Post-menopausal
< 9.5
INVESTIGATIONS: B-HCG
urine pregnancy tests can detect as low as 20-50 IU/L
 serum tests can detect levels as low as 5 IU/L
 The rate of increase is reassuring, but NOT indicative
of a normal pregnancy

if too low: ectopic vs. failing intrauterine pregnancy
 if too high: consider gestational trophoblastic disease

INVESTIGATIONS: ULTRASOUND
Trans-vaginal usually better than trans-abdominal
 Extremely valuable in assessing early pregnancy,
gestational age, viability, and cause for bleeding
 Can often be arranged very quickly upon request
 In Ottawa, several US locations are specific for
OBGYN issues

INVESTIGATIONS: ULTRASOUND

Ectopic pregnancy
suspect ectopic if trans-abdo US shows no intrauterine
gestational sac with B-hcG >6500 IU/L or trans-vag US
shows no sac with B-hcG >1500 IU/L
 difficult to determine whether an empty uterus indicates
early pregnancy or ectopic pregnancy.
 1/4000 chance of heterotopic pregnancy, with up to 1% in
women undergoing fertility treatment

INVESTIGATIONS: ULTRASOUND

Other valuable findings:

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Twin pregnancy (or “vanished twin”)
Sub-chorionic bleed (up to 20% of pregnancies)
Discrepancy in dates
Blighted ovum
Missed abortion
US showing viability is very reassuring to the patient,
especially if she has had a previous miscarriage
PREGNANCY LOSS

8-15 % of recognized pregnancies end in miscarriage

70 % due to fetal factors
Non-recurring chromosomal anomalies
 Placental abnormalities


30 % due to maternal factors
advancing maternal and/or paternal age
 obesity
 Substance use
 maternal chronic disease
 maternal infections
 Medications or other exposures

MANAGEMENT

3 reasonable options:
Expectant management
 Medical management
 Surgical management

EXPECTANT MANAGEMENT
highly effective for incomplete abortion
 90% success rate for incomplete abortion, but can
takes weeks for complete passage of tissue
 Repeat U/S showing the absence of a previously
documented pregnancy or an 80% drop in the B-hcG 1
week after the passage of tissue confirms completion
 Only need to follow B-hcG to 0 if ectopic has not been
completely excluded

MEDICAL MANAGEMENT
Misoprostol used in Canada (off label use)
 Doses in published studies are 400 – 800 mcg PV or
600 mcg oral, to be repeated at 12-24 hours 3-4 times
(PV has less GI side effects, oral may be less effective)
 Appropriate for missed abortion, incomplete abortion
or blighted ovum
 NSAID’s or Tylenol #3 can be used to block adverse
effects of fever, chills, and cramping

MEDICAL MANAGEMENT
Patients experience cramping and bleeding can be
quite heavy
 For some patients this is an intense and frightening
experience
 Explain to the patient what to expect and options for
after-hours care
 Some OBGYN’s recommend FU US after 1-2 weeks
and repeat B-hcG to ensure completion of the abortion

SURGICAL MANAGEMENT


D&C can be done for any type of 1st trimester loss
At the Ottawa Hospital, can refer patient to
Manual Vacuum Aspiration Program at the
Riverside



Fax: (613) 738-8524
Send history, US report, CBC and
blood type
Exclusions: EGA>10 weeks, molar,
uncontrolled maternal illness
including anxiety and obesity, bleeding
disorder etc.
RHOGAM
For those women who are Rh negative,
Rhogam/Winrho should be offered
 At TOH, Transfusion Medicine will release Rhogam if
blood group and screen are on file
 150-300 units given IM, ideally within 72 hours of
pregnancy loss, but can still be given afterwards
 Remember that this is a blood product

WEBSITES
www.maternitycarecalendar.com/about_maternity.
cfm
www.dfcm.utoronto.ca/research/alpha/default.htm
www.csep.ca
www.dfcm.utoronto.ca/research/prima/Home.html
http://www.mountsinai.on.ca/care/family-medicinegenetics-program/prenatal
www.cheo.on.ca/english/8000_genetics.shtm
http://www.sogc.org/guidelines/
REFERENCES
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