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Guideline Summary
Guideline Title
VA/DoD clinical practice guideline for management of pregnancy.
Bibliographic Source(s)
Department of Veteran Affairs, Department of Defense. VA/DoD clinical practice guideline for management of pregnancy. Washington (DC): Department of Veteran Affairs, Department of Defense; 2009. 163 p.
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: U.S. Department of Veteran Affairs, Veterans Health Administration, Veterans Health Administration. DoD/VA clinical practice guideline for the management of uncomplicated pregnancy. Washington (DC): Department of Veteran Affairs; 2002 Oct. Various p. [533 references]

Scope

Disease/Condition(s)
  • Pregnancy
  • Complications of pregnancy
Guideline Category
Counseling
Evaluation
Management
Prevention
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Medical Genetics
Nursing
Obstetrics and Gynecology
Preventive Medicine
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Guideline Objective(s)

To improve pregnant woman and provider satisfaction with antenatal care using the following approaches:

  • Outlining antenatal visits for specific gestational ages, with each visit having specific well-defined goals and objectives.
  • Helping ensure both pregnant women and providers are aware of the specific expectations for each visit, thus promoting a partnership with the common goal of a healthy infant and mother. Enhanced patient education will be a hallmark of this healthcare partnership and the goal-oriented prenatal care system.
  • Presenting a standardized care plan in the Pregnancy Guideline that is expected to improve overall patient satisfaction and lessen inter-provider variability, which is often perceived by pregnant women in a negative manner and as a sign of clinical naiveté and uncertainty.
  • Providing a scientific evidence-base for practice interventions and evaluations.
Target Population

Pregnant women

Note: The guideline will not address specific intra-partum or post-partum needs.

Interventions and Practices Considered

Screening/Assessment

  1. Screening for hypertensive disorders and gestational diabetes
  2. Screening for tobacco, alcohol, and drug use
  3. Screening for infections (rubella, varicella, hepatitis B, tuberculosis, bacteriuria, group B streptococcal)
  4. Screening for sexually transmitted diseases (gonorrhea, chlamydia, syphilis, human immunodeficiency virus [HIV], herpes simplex virus [HSV])
  5. Screening for blood type (ABO, Rh) and antibody status
  6. Screening for anemia
  7. Screening for depression
  8. Screening for domestic abuse
  9. Screening for hemoglobinopathies and fetal chromosomal abnormalities if indicated
  10. Assessment of fetal heart tones, fetal presentation, and fundal height
  11. Establishing gestational age
  12. Assessment of inappropriate weight gain
  13. Assessment of risk factors for preterm labor
  14. Assessment of periodontal disease
  15. Obstetric ultrasound

Counseling/Education/Interventions

  1. Education regarding breastfeeding, prenatal screening, exercise, and shaken baby syndrome
  2. Counseling for cystic fibrosis screening, family planning, and trial of labor after previous cesarean delivery, if indicated
  3. Immunizations
  4. Nutritional and iron supplementation
  5. Anti-D prophylaxis for Rh-negative women
  6. Weekly cervical check/stripping
  7. Management of obesity
  8. Management of depression
  9. Treatment for hepatitis B

Interventions Not Recommended in Routine Prenatal Care

  1. Screening with fetal fibronectin
  2. Cervical examination
  3. Antenatal pelvimetry
  4. Urine dipstick test
  5. Edema evaluation
  6. Screening for cytomegalovirus (CMV)
  7. Screening for parvovirus
  8. Screening for toxoplasmosis
  9. Screening for bacterial vaginosis
  10. Immunization – measles, mumps, rubella (MMR)
  11. Immunization – Varicella
  12. Ultrasound (US) evaluation of cervical length at week 24
  13. Repeat screening for anemia, syphilis, and isoimmunization
  14. Screening for hypothyroidism
Major Outcomes Considered
  • Sensitivity and specificity of screening tests
  • Risk factors for preterm birth
  • Effectiveness of timely comprehensive screening
  • Effectiveness of counseling and education

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Formulation of Questions

The Working Group developed researchable questions and associated key terms after orientation to the scope of the guideline and to goals that had been identified by the Working Group. The questions specified (adapted from the Evidence-Based Medicine toolbox, Centre for Evidence-Based Medicine, [http://cebm.net External Web Site Policy])

  • Population – Characteristics of the target patient population
  • Intervention – Exposure, diagnostic, or prognosis
  • Comparison – Intervention, exposure, or control used for comparison
  • Outcome – Outcomes of interest

These specifications served as the preliminary criteria for selecting studies. Literature searches were conducted on all topics identified in the algorithm or recommendations of the original guidelines. After reviewing the initial search for systematic reviews and meta-analyses, the Working Group decided to focus the search for individual randomized controlled trials (RCTs) on specific interventions specified in a list of questions (for list of the questions see Appendix F in the original guideline).

The evidence selection was designed to identify the best available evidence to address each key question and ensure maximum coverage of studies at the top of the hierarchy of study types. Published, peer-reviewed RCTs, as well as meta-analyses and systematic reviews that included randomized controlled studies, were considered to constitute the strongest level of evidence in support of guideline recommendations. This decision was based on the judgment that RCTs provide the clearest, scientifically sound basis for judging comparative efficacy. The Working Group made this decision recognizing the limitations of RCTs, particularly considerations of generalizability with respect to patient selection and treatment quality. When available, the search sought out critical appraisals already performed by others that described explicit criteria for deciding what evidence was selected and how it was determined to be valid. The sources that have already undergone rigorous critical appraisal include Cochrane Reviews, Best Evidence, Technology Assessment, and Agency for Healthcare Research and Quality (AHRQ) systematic evidence reports.

In addition to Medline/PubMed, the following databases were searched: Database of Abstracts of Reviews of Effectiveness (DARE) and Cochrane Central Register of Controlled Trials. For Medline/PubMed searches, limits were set for language (English), and type of research (RCT, systematic reviews and meta-analysis).

As a result of the literature reviews, articles were identified for possible inclusion. These articles formed the basis for formulating the guideline recommendations. The following inclusion criteria were used for studies:

  • English language only of studies performed in United States, United Kingdom, Europe, Australia, Japan, New Zealand
  • Full articles only
  • Study populations limited to adults age 17 years or above; all races, ethnicities, cultural groups
  • Randomized controlled trials or prospective studies
  • Published from 2002 to December 2007

Seed Guidelines

  • Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for the Management of Uncomplicated Pregnancy (2001).
  • Institute for Clinical Systems Improvement (ICSI) – Health Care Guideline: Routine Prenatal Care, July 2000.
  • Guide to Clinical Preventive Services (CPS) Second Edition, Report of the U.S. Preventive Services Task Force, 1996.
  • National Institute for Health and Clinical Excellence – Clinical Guidelines (UK), 2003.
  • American College of Obstetricians and Gynecologists (ACOG) technical bulletins and guidelines as a respected source for expert opinion.

Admissible evidence (study design and other criteria):

  • Original research studies that provide sufficient detail regarding methods and results to enable use and adjustment of the data and results.
  • Randomized controlled trials; systematic reviews (including evidence-based practice center [EPC] and health technology assessment [HTA] reviews); and meta-analyses.
  • Relevant outcomes must be able to be abstracted from data presented in the articles.
  • Sample sizes must be appropriate for the study question addressed in the paper. RCTs were included if they were initiated with 30 or more participants.
Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Quality of Evidence

I At least one properly done randomized controlled trial (RCT)
II-1 Well-designed controlled trial without randomization
II-2 Well-designed cohort or case-control analytic study, preferably from more than one source
II-3 Multiple time series evidence with/without intervention, dramatic results of uncontrolled experiment
III Opinion of respected authorities, descriptive studies, case reports, and expert committees

Overall Quality

Good High grade evidence (I or II-1) directly linked to health outcome
Fair High grade evidence (I or II-1) linked to intermediate outcome;
or
Moderate grade evidence (II-2 or II-3) directly linked to health outcome
Poor Level III evidence or no linkage of evidence to health outcome

Net Effect of the Intervention

Substantial More than a small relative impact on a frequent condition with a substantial burden of suffering, or
A large impact on an infrequent condition with a significant impact on the individual patient level
Moderate A small relative impact on a frequent condition with a substantial burden of suffering, or
A moderate impact on an infrequent condition with a significant impact on the individual patient level
Small A negligible relative impact on a frequent condition with a substantial burden of suffering, or
A small impact on an infrequent condition with a significant impact on the individual patient level
Zero or Negative Negative impact on patients, or
No relative impact on either a frequent condition with a substantial burden of suffering, or an infrequent condition with a significant impact on the individual patient level
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Preparation of Evidence Tables (Reports) and Evidence Rating

The results of the search were organized and evidence reports as well as copies of the original studies were provided to the Working Group for further analysis. Each study was appraised by a group of research analysts for scientific merit, clinical relevance, and applicability to the populations served by the Federal healthcare system. The body of evidence was rated for quality and level of evidence.

Recommendation and Overall Quality Rating

Evidence-based practice involves integrating clinical expertise with the best available clinical evidence derived from systematic research. The Working Group received an orientation and tutorial on the evidence U.S. Preventative Services Task Force (USPSTF) 2001 rating process, reviewed the evidence and independently formulated Quality of Evidence ratings, a rating of Overall Quality (see the "Rating Scheme for the Strength of the Evidence" field), and a Strength of Recommendation (see the "Rating Scheme for the Strength of the Recommendation" field).

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Guideline Development Process

The development update of the Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline for Pregnancy Management followed the steps described in "Guideline for Guidelines," an internal working document of the VA/DoD Evidence-Based Practice Working Group that requires an ongoing review of the work in progress. The Working Group of the VA/DoD was charged with updating the evidence-based action recommendations whenever possible.

The Offices of Quality and Performance and Patient Care Services, in collaboration with the network Clinical Managers, the Deputy Assistant Under Secretary for Health, and the Medical Command of the DoD, identified clinical leaders to champion the guideline development process. During a preplanning conference call, the clinical leaders defined the scope of the guideline and identified a group of clinical experts from the VA and DoD that formed the Pregnancy Management Working Group. Working Group members included representatives of the following specialties: family practice, obstetrics/gynecology (OB/GYN) (prenatal care), nursing, midwifery, genetic counseling, psychology/psychiatry (mental health), maternal fetal medicine specialist, and pharmacy.

The Working Group defined a set of clinical questions within the area of the guideline. This ensured that the guideline development work outside the meeting focused on issues that practitioners considered important and produced criteria for the search and the protocol for systematic review and, where appropriate, meta-analysis.

The Working Group participated in an initial face-to-face meeting to reach consensus about the guideline algorithm and recommendations, and to prepare a draft update document. The draft continued to be revised by the Working Group at-large through numerous conference calls and individual contributions to the document. Following the initial effort, an editorial panel of the Working Group convened to further edit the draft document. Recommendations for the performance or inclusion of specific procedures or services were derived through a rigorous methodological approach that included the following:

  • Determining appropriate criteria, such as effectiveness, efficacy, population benefit, or patient satisfaction
  • Reviewing literature to determine the strength of the evidence in relation to these criteria
  • Formulating the recommendations and grading the level of evidence supporting the recommendation.

This update of the uncomplicated pregnancy (UCP) guideline is the product of many months of diligent effort and consensus building among knowledgeable individuals from the VA, DoD, academia, as well as guideline facilitators from the private sector. An experienced moderator facilitated the multidisciplinary Working Group.

Lack of Evidence – Consensus of Experts

Where existing literature was ambiguous or conflicting, or where scientific data were lacking on an issue, recommendations were based on the clinical experience of the Working Group.

Rating Scheme for the Strength of the Recommendations

Final Grade of Recommendation

  The net benefit of the intervention 
Quality of Evidence Substantial Moderate Small Zero or
Negative
Good A B C D
Fair B B C D
Poor I I I I

Evidence Rating System

A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Cost Analysis

Published cost analyses were reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

The feedback from the experts from the Department of Veterans Affairs (VA) and Department of Defense (DoD) was integrated into the final draft document.

Recommendations

Major Recommendations

The recommendations for the management of pregnancy are provided in the form of an algorithm, annotations, and a summary chart that describes the interventions that should take place throughout the goal-oriented prenatal visits during pregnancy. The level of evidence (LE) grading (I-III); overall quality of evidence (QE) (Good, Fair, Poor); and strength of recommendation (SR) (A-D, I) are provided for specific statements. These grades, along with "net effect of the interventions" are defined at the end of the "Major Recommendations" field.

A-0. Organization of Prenatal Care

Recommendations

  1. Goal-oriented prenatal care system can be delivered to all pregnant women. [B]
  2. Education should be a central component of prenatal care for all pregnant women. [B]
  3. Group model of prenatal care, such as the Centering Pregnancy® model, is an acceptable alternative to individual provider appointments. [A]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Effect of reduced number of visits Villar et al., 2001 I Fair B
Partridge & Holman, 2005 II
2 Group prenatal care is an acceptable alternative to individual appointments and can result in equal or improved perinatal outcomes Ickovics et al., 2007; Baldwin, 2006 I Good A

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

A-1. Confirmed Pregnancy

Confirmation of pregnancy is established by a confirmed positive urine or serum pregnancy test.

A-2. First Visit with Nurse: Weeks 6 to 8; Complete Self-Questionnaire; Assess for Risk Factors

Recommendations

  1. Initial assessment by nurse may include the following actions:
    • Assure the patient completes the Self-Questionnaire (see Appendix B - "Screening Items for Self-Administered Questionnaire – First Visit" in the original guideline)
    • Review the patient's completed Self-Questionnaire for issues requiring immediate evaluation or intervention (see Appendix B - "Screening Items for Self-Administered Questionnaire – First Visit" in the original guideline)
    • Obtain initial prenatal lab tests to be reviewed and documented at the following visit
    • Consult with an advanced prenatal care provider regarding advice or instruction to the patient if there are immediate needs (see Table 1, "Prenatal Risk Assessment by Nurse - Checklist" in the original guideline)
    • Arrange immediate referral to advanced prenatal care for follow-up in cases needing short-term assessment or intervention (see Table 1 in the original guideline)
    • Provide brief information about options for screening for fetal chromosomal abnormalities and arrange for counseling (See section I-36 below)
    • Arrange follow-up with the appropriate provider at 10 to 12 weeks.

A-3. The First Provider Visit: Weeks 10 to 12

Recommendations

  1. At the first provider visit, a complete medical history and physical examination (including thyroid, breast and pelvic examination) should be obtained. Information from the previous visit(s) and laboratory studies should be reviewed and significant problems/risks should be assessed.
  2. At the first provider visit, the provider should outline an individualized plan of prenatal care that includes guideline-based routine prenatal care and consultation with advanced prenatal care providers or other medical specialty care services if needed.
  3. The following are conditions not addressed by this guideline that will require supplemental care that might be best provided by routine or advanced obstetric care providers and/or behavioral health providers depending on the individual circumstances and local conditions:
    • Current mental illness requiring medical therapy
    • Substance use disorders
    • Eating disorders
  4. The following are among conditions that require supplemental prenatal care or consultation with or referral to an advanced prenatal care provider (see Table 2 in the original guideline):
    • General
      • Body mass index (BMI) <16.5 or >30
      • Age (<16 or > 34 years at delivery)
      • At risk for diabetes
    • Infections
    • Pre-existing medical conditions
    • Obstetric conditions

See the original guideline for the detailed list of conditions requiring supplemental prenatal care.

A-4. Assessment of Risk Factors for Preterm Birth

Recommendations

Assessment of Preterm Birth

  1. Women should be assessed for preterm birth risk as early as possible in the pregnancy in order to optimize maternal and newborn outcomes.
  2. Screening for preterm birth risk factors should continue up to 37 weeks estimated gestational age.
  3. Women at increased risk but meeting the criteria for normal surveillance should have the risk factor(s) documented in the medical record to increase awareness of the risk but may continue to be followed in accordance with the routine management of the pregnancy guideline.
  4. Routine care providers should consult with an advanced prenatal care provider whenever a woman meets the criteria for increased surveillance for preterm birth.
  5. Women requiring increased surveillance should be considered for ancillary studies and other additional intervention. Progesterone supplementation should be considered in these women (see section A-4 below).
  6. Routine screening of fetal fibronectin (fFN) in asymptomatic or low-risk women is not recommended (see section I-52 below). fFN testing in symptomatic or high-risk women between 24 and 34 6/7 weeks' gestation may be useful in guiding management.
  7. The measurement of cervical length by transvaginal ultrasound may be useful in some patients requiring increased surveillance for preterm labor. Sonographic cervical length measurement is not recommended as a routine screening or prediction tool in women only requiring normal surveillance.
  8. The determination of salivary estriol levels, bacterial vaginosis screening and home uterine activity monitoring are not recommended as a means to predict preterm birth.

Progesterone Therapy

  1. It is reasonable to offer antenatal progesterone therapy to women at high-risk for preterm delivery and who meet the generally accepted inclusion criteria. [B]
  2. Progesterone may be administered intramuscularly on a weekly basis or intravaginally on a daily basis. [B]
  3. Progesterone therapy should only be initiated after consultation with an advanced prenatal care provider (obstetrician or maternal-fetal medicine specialist). [C]

See Table 3 in the original guideline for risk factors for preterm birth.

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Offer progesterone therapy to women at risk for recurrent preterm birth da Fonseca et al., 2003; Fonseca et al., 2007; Meis et al., 2003 I Fair B
2 Progesterone may be administered intramuscularly or intravaginally American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics, 2003 III Poor B
da Fonseca et al., 2003 I Good
Fonseca et al., 2007 I Fair
Meis et al., 2003 I Good
3 Progesterone should be initiated after consultation with obstetrician or MFM specialist ACOG Committee on Practice Bulletins, 2003; Working Group Consensus III Poor C
4 Surveillance and intervention based on risk stratification for preterm birth Working Group Consensus III Poor I

LE, level of evidence; MFM, maternal-fetal medicine; QE, quality of evidence; SR, strength of recommendation

A-7. Postpartum Visit

Recommendations

  1. The following should be included in the postpartum visit:
    • Pelvic and breast examinations. [B]
    • Cervical smear should be completed as indicated by cervical cancer screening guidelines (see section I-31). [A]
    • Initiate or continue the human papillomavirus (HPV) vaccine series for women age < 26 years (see section I-50). [C]
    • Screening for postpartum depression (see section I-21). [B]
    • Screening for domestic violence (see section I-20). [B]
    • Diabetes testing for patients with pregnancies complicated by gestational diabetes. The two-hour 75g oral glucose tolerance test (GTT) is recommended but a fasting glucose can also be done. [B]
    • Education about contraception, infant feeding method, sexual activity, weight, exercise and the woman’s assessment of her adaptation to motherhood. Pre-existing or chronic medical conditions should be addressed with referral for appropriate follow-up as indicated. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Postpartum visit at eight weeks Rarick & Tchabo, 1994 I Good B
2 Tests traditionally performed at this visit include the cervical smear, pelvic exam, and breast exam. The Pap smear may be deferred in women without a history of abnormal Pap smears and whose Pap smear remains current Jazayeri et al., 1999; Londo et al., 1994; Weiss, Senf, & Udall, 1989 II Fair B
3 Diabetes screening in women whose pregnancies were complicated by GDM ACOG, 2001; Conway & Langer, 1999 II Fair B

GDM, gestational diabetes mellitus; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

Interventions at All Visits

See the Summary Table, "Prenatal Care Interventions" in the original guideline for the interventions that all pregnant women should undergo, the specific week the intervention should be completed, and the interventions not recommended in routine prenatal care.

I-1. Screening for Hypertensive Disorders of Pregnancy: Weeks (All)

Recommendations

  1. Recommend measuring blood pressure of all pregnant women at each prenatal visit, following the guidelines of the National High Blood Pressure Education Program and the Department of Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guidelines for Hypertension. [B]
  2. Women diagnosed with hypertension during pregnancy should be managed by, or in consultation with, an advanced prenatal care provider. [C]
  3. Korotkoff 5 sound (disappearance of sound) will be used to determine the diastolic pressure. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine blood pressure screening at each prenatal visit ACOG Committee on Practice Bulletins, 2001; National Institutes of Health (NIH), National Heart, Lung, and Blood Institute, 2000 III Good B
2 Women diagnosed with hypertension may require a higher level of care ACOG Committee on Practice Bulletins, 2001; Cunningham & Lindheimer, 1992; NIH, National Heart, Lung, and Blood Institute, 2000 III Poor B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-2. Breastfeeding Education: Weeks (All)

Recommendations

  1. Recommend offering breastfeeding education to all pregnant women during the first visit with the provider. [B]
  2. Recommend asking pregnant women, "What do you know about breastfeeding?" rather than, "Do you plan on breast or bottle feeding?" to provide an open opportunity for education. [B]
  3. Recommend continuing education throughout pregnancy for those pregnant women who express a desire to breastfeed or for those who are still undecided on feeding method. [C]
  4. Recommend including family/significant others in breastfeeding education. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Breastfeeding inquiry Hartley & O'Connor, 1996 II-2 Fair B
2 Breastfeeding education Hill & Humenick, 1993 III Fair B
Hill, 1991 II-3
3 Longitudinal breastfeeding education Berens, 2001 III Fair C
4 Family/significant other participation in breastfeeding education Berens, 2001 III Fair B
Humenick, Hill, & Wilhelm, 1997 II-1

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-3. Exercise During Pregnancy: Weeks (All)

Recommendations

  1. Strongly recommend all healthy, pregnant women perform regular mild to moderate exercise sessions, three or more times per week. [A]
  2. Recommend individualized exercise programs for all pregnant women, based on their pre-pregnancy activity level. [I]
  3. Recommend against high-altitude (>10,000 feet) activities, scuba diving, and contact sports during pregnancy. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Regular exercise for all pregnant women "Exercise during pregnancy," 1994; Campbell & Mottola, 2001; Clapp, Lopez, & Harcar-Sevcik, 1999; Clapp et al., 2000; Clapp, 2001; Kramer & McDonald, 2006; Morris & Johnson, 2005; Sady et al., 1989; Sternfeld et al., 1995 I Good A
2 Individualized exercise programs, based on the woman's pre-pregnancy activity level "Exercise during pregnancy," 1994; Clapp, Lopez, & Harcar-Sevcik, 1999; Sternfeld et al., 1995 II-2 Good B
3 High altitude, contact sports and scuba diving (not recommended) Alderman et al., 1995; Camporesi, 1996; Hammer, Perkins, & Parr, 2000 II-2 Good D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-4. Influenza Vaccine (Season-Related): Weeks (Any Week)

Recommendations

  1. Recommend immunizing all pregnant women for influenza during the epidemic season. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Influenza immunization ACOG Committee on Obstetric Practice, 2004; Englund, Glezen, & Piedra, 1998 II Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

First Visit with Nurse (6 to 8 Weeks)

I-5. Screening for Tobacco Use – Offer Cessation: Weeks 6 to 8

Recommendations

  1. Strongly recommend routine screening for tobacco use in pregnancy at the initial prenatal visit. For patients who smoke, recommend assessment of smoking status at each subsequent prenatal visit. [A]
  2. If the screening is positive, cessation should be strongly recommended. [A]
  3. There is insufficient data to recommend for or against pharmacologic therapy for tobacco cessation in pregnancy. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Screening for tobacco use Mullen et al., 1991; Lumley et al., 2004 I Good A
2 Cessation of tobacco use Dolan-Mullen, Ramirez, & Groff, 1994; Panjari et al., 1999; Wisborg et al., 2000 I Good A

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-6. Screening for Alcohol Use – Offer Cessation: Weeks 6 to 8

Recommendations

  1. Recommend routine screening for alcohol consumption using a standardized tool (refer to the National Guideline Clearinghouse [NGC] summary of the Department of Veterans Affairs/Department of Defense [VA/DoD] Clinical Practice Guideline for the Management of Substance Use Disorders). [B]
  2. If the screening is positive, cessation should be strongly recommended. [B]
  3. There is insufficient evidence regarding which cessation intervention tool is the most effective. [I]
  Recommendations Source of Evidence LE QE SR
1 Screening for evidence of problem drinking, using a standardized tool Chang et al., 1999; Handmaker, Miller, & Manicke, 1999; Reynolds et al., 1995 I Fair B
2 If the screening is positive, recommend cessation Chang et al., 1999; Handmaker, Miller, & Manicke, 1999; Reynolds et al., 1995 I Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-7. Screening for Drug Use – Offer Treatment: Weeks 6 to 8

Recommendations

  1. Recommend routine screening for illicit drug use using a self-report method. [C]
  2. Recommend pregnant women identified as abusing drugs be offered treatment and receive care in consultation with or referral to an advanced prenatal care provider. (See also the NGC summary of the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders.) [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine screening for illicit drug use Horrigan, Piazza, & Weinstein, 1996 II-2 Fair C
2 If the screening is positive, offer treatment Howell, Heiser, & Harrington, 1999 II-3 Fair C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-8. Screening for Blood Type (ABO, Rh) and Antibody Status: Weeks 6 to 8

Recommendations

  1. Recommend evaluation of maternal blood group system (ABO) and rhesus factor (Rh) blood type and blood antibody status at the initial prenatal visit. [B]
  2. Pregnant women with positive antibody screens should be referred for consultation to assist with further management. [C] (see section I-42)
  3. There is insufficient evidence to recommend for or against routine repeat testing at 28 weeks' gestation. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Antibody screening Bowell, Allen, & Entwistle, 1986 II-2 Good B
2 Rh status screening Howard et al., 1998 II-2 Fair C
3 Repeat screening at 28 weeks Working Group Consensus III Poor I

LE, level of evidence; QE, quality of evidence; Rh, rhesus factor; SR, strength of recommendation

I-9. Screening for Rubella: Weeks 6 to 8

Recommendations

  1. Recommend all pregnant women have a serum screen for rubella status at the initial prenatal visit. [B]
  2. Recommend seronegative pregnant women be counseled to avoid exposure. [B]
  3. Recommend seronegative pregnant women be vaccinated in the immediate postpartum period. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Serum screening for rubella status at the initial prenatal visit McElhaney et al., 1999 II-2 Fair B
2 Counseling seronegative pregnant women to avoid exposure Working Group Consensus III Poor B
3 Vaccinating seronegative pregnant women in the immediate postpartum period Horstman et al., 1985 II-2 Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-10. Screening for Varicella: Weeks 6 to 8

Recommendations

  1. Recommend routine screening for varicella through history. [B]
  2. If negative/unsure history, obtain a varicella titer. [B]
  3. Recommend offering vaccination postpartum, if varicella is non-immune. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine varicella screening Smith et al., 1998 I Good B
2 Postpartum varicella immunization in seronegative pregnant women Marin et al., 2007 I Good B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-11. Screening for Hepatitis B Virus (HBV): Weeks 6 to 8

Recommendations

  1. Recommend routine laboratory screening for hepatitis B surface antigen at the initial prenatal visit. [A]
  2. Repeat laboratory screening of pregnant women with identification of hepatitis risk factors during the pregnancy (e.g., healthcare worker, intravenous [IV] drug use, exposure to hepatitis, visit for evaluation or therapy for sexually transmitted infections, and new tattoos and blood transfusions). [C]
  3. Vaccinate pregnant women with hepatitis risk factors who have not been previously vaccinated. [B]
  4. Women at risk for HBV infection in pregnancy should be counseled concerning additional methods to prevent HBV infection. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Screen for hepatitis B at first prenatal visit ACOG, "Viral hepatitis," 2007 I Good A
2 Rescreen pregnant women with risk factors for hepatitis Duff, 1998 III Fair C
3 Vaccinate pregnant women with hepatitis risk factors who have not been previously vaccinated Mast et al., 2005 II Good B
4 Pregnant women at risk for HBV infection during pregnancy should be counseled concerning other methods of preventing HBV infection Mast et al., 2005 III Fair C

HBV, hepatitis B virus; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-12. Treatment for Hepatitis B Infection: Week 36

Recommendations

  1. Treat all infants born to hepatitis B positive mothers with hepatitis B immunoglobulin and initiate hepatitis B vaccination within 12 hours of birth. [A]
  2. Strongly consider treating infants born to women at high risk for hepatitis B who have not been vaccinated or whose infectious status is unknown. [B]
  3. Consider treating women who have high copy numbers of HBV-deoxyribonucleic acid (DNA) with lamivudine during the last month of pregnancy. [B]
  4. Women with HBV infection should be taught, and encouraged to implement, strategies to decrease transmission to non-infected intimate contacts. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Active and passive immunization of neonates born to HBV-positive mothers within 12 hours of birth Sangfelt et al., 1995; Michielsen & Van Damme, 1999; ACOG, "Viral hepatitis," 2007 I Good A
2 Strongly consider treating infants born to women at high risk for hepatitis B who have not been vaccinated or whose infectious status is unknown ACOG, "Viral hepatitis," 2007 I Good B
3 Consider treating women who have high copy numbers of HBV-DNA with lamivudine during the last month of pregnancy Li et al., 2004; van Zonneveld et al., 2003; Xu et al., 2004 I Good B
4 Teach and encourage women with HBV to implement strategies to decrease transmission to non-infected intimate contacts ACOG, "Viral hepatitis," 2007; Mast et al., 2005 II Fair B

DNA, deoxyribonucleic acid; HBV, hepatitis B virus; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-13. Screening for Syphilis Rapid Plasma Reagin (RPR): Weeks 6 to 8

Recommendations

  1. Recommend routine screening for syphilis using serologic testing (i.e., RPR or Venereal Disease Research Laboratory [VDRL]) at the initial prenatal visit. [B]
  2. Recommend a confirmatory test using a more specific treponemal assay (fluorescent treponemal antibody absorption assay [FTA-ABS], microhemagglutination assay [MHS-TP], hemagglutination treponemal test for syphilis [HATTS]) for pregnant women who test positive. [B]
  3. Strongly recommend therapy with penicillin G antibiotic for pregnant women who have confirmed syphilis, as recommended by other sexually transmitted disease (STD) guidelines. [A]
  4. Recommend appropriate medical and legal mandates, follow-up and state/service reporting requirements for pregnant women screening positive. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine syphilis screening Donders et al., 1993; Dorfman & Glaser, 1990 II-3 Fair B
2 Confirmatory syphilis testing in pregnant women with positive screens Hart, 1986 II-2 Fair B
3 Treatment of confirmed positive Centers for Disease Control and Prevention (CDC), 1998 II-2 Fair A

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-14. Screening for Asymptomatic Bacteriuria (ASB): Weeks 6 to 8

Recommendations

  1. Strongly recommend screening for ASB at initial obstetrical visit via urine culture and sensitivity. [A]
  2. There is insufficient evidence to recommend for or against repeat screening throughout the remainder of pregnancy. [I]
  3. Strongly recommend a three to seven-day course of appropriate antibiotics based on positive culture and sensitivity, and woman's history of medication allergies. [A]
  4. There is insufficient evidence to recommend for or against a test of cure (TOC) after completion of antibiotic therapy, except in pregnant women with ASB-Group B Strep. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Screening for ASB at the initial prenatal visit by urine culture Romero et al., 1989; Smaill, 2001; United States Preventive Services Task Force (USPSTF), 2008 I Good A
2 Repeat screening throughout pregnancy Working Group Consensus III Poor I
3 A three- to seven-day course of appropriate antibiotics based on positive culture and sensitivity, and woman's history of medication allergies Smaill, 2001 I Good A
4 TOC after completion of antibiotic therapy Working Group Consensus III Poor I

ASB, asymptomatic bacteriuria; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation; TOC, test of cure

I-15. Screening for Tuberculosis: Weeks 6 to 8

Recommendations

  1. All pregnant women from one or more high-risk groups should be screened for tuberculosis with a Mantoux test with purified protein derivative (PPD) soon after the pregnancy is diagnosed. [C]
  2. Pregnant women with a positive PPD with known conversion in the last two years and no clinical or X-ray evidence of disease should be treated with isoniazid (300 mg per day) starting after the first trimester and continuing for nine months. [C]
  3. For pregnant women with a positive PPD whose time of conversion is unknown and who have no clinical or x-ray evidence of disease present, consider delaying therapy until after the pregnancy. [C]
  4. Pregnant women with active tuberculosis should be treated with multi-drug therapy including isoniazid and rifampin, supplemented by ethambutol if isoniazid drug resistance is suspected. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 All pregnant women from one or more high-risk groups should be screened for tuberculosis with a Mantoux test with purified protein derivative (PPD) soon after the pregnancy is diagnosed American Academy of Pediatrics (AAP), 1998; "Targeted tuberculin testing," 2000; ACOG Committee on Gynecologic Practice, 2006 III Fair C
2 Pregnant women with a positive PPD with known conversion in the last two years and no clinical or x-ray evidence of disease should be treated with isoniazid (300 mg per day) starting after the first trimester and continuing for nine months AAP, 1998 II Fair C
"Targeted tuberculin testing," 2000 III
3 For pregnant women with a positive PPD whose time of conversion is unknown and who have no clinical or x-ray evidence of disease present, consider delaying therapy until after the pregnancy AAP, 1998; "Targeted tuberculin testing," 2000 II Fair C
4 Pregnant women with active tuberculosis should be treated with multi-drug therapy including isoniazid and rifampin, supplemented by ethambutol if isoniazid drug resistance is suspected AAP, 1998; "Targeting tuberculin testing," 2000 III Fair C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-16. Screening for Human Immunodeficiency Virus (HIV) – Counsel: Weeks 6 to 8

Recommendations

  1. Strongly recommend routine testing for HIV infection at the initial prenatal visit. [A]
  2. Pregnant women who test positive for HIV should be referred for treatment and counseling. [I]
  3. Recommend retesting all high-risk pregnant women during the early third trimester and offer repeat testing for patients who refused the first test. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine HIV screening AAP/ACOG, 1995 I Good A
2 Retest high-risk women Higgins et al., 1991; Tookey et al., 1998 II-2 Fair B

HIV, human immunodeficiency virus; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-17. Screening for Tetanus-Diphtheria (Td) and Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Booster: Weeks 6 to 8

Recommendations

  1. Strongly recommend routine screening for Tdap booster status at the initial prenatal visit. [A]
  2. If there is no documentation of Td booster within the last 10 years: [A]
    • Provide Tdap in the immediate postpartum period before discharge from the hospital or birthing center
    • May provide Tdap at an interval as short as two years since the most recent Td vaccine
    • Provide Td during pregnancy for tetanus and diphtheria protection when indicated, or defer the Td vaccine indicated during pregnancy to substitute Tdap vaccine in the immediate postpartum period if the woman is likely to have sufficient protection against tetanus and diphtheria
  3. Td booster should be provided if indicated. There are no contraindications other than a previous severe reaction to Td vaccination, such as anaphylaxis, generalized urticaria, or angioedema. [A]
  4. 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]

Evidence Table

  Recommendations Source 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 & Francis, 1998; Institute for Clinical Systems Improvement (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 & Francis, 1998; ICSI, 2001; USPSTF, 1996 II-2 Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation; Td, tetanus-diphtheria

I-18. Screening for Anemia: Weeks 6 to 8

Recommendations

  1. All pregnant women should be screened for anemia during pregnancy with a hematocrit or hemoglobin measurement during the first visit. [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. Red blood cell transfusion should be considered for pregnant women with severe anemia. [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. [C]

Evidence Table

  Recommendations Source 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 ACOG, "Anemia," 2008; "Recommendations to prevent and control iron deficiency," 1998 III Fair 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) ACOG, "Anemia," 2008; Institute of Medicine, 1993; Reveiz, Gyte, & Cuervo, 2007 II, III Fair C
3 Red blood cell transfusion should be considered for pregnant women with severe anemia ACOG, "Anemia," 2008 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, "Anemia," 2008; Faich & Strobos, 1999; Bhandal & Russell, 2006 III Fair C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-19. Screening for Hemoglobinopathies: Weeks 6 to 8

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]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Offer carrier screening to individuals of African, Southeast Asian, and Mediterranean descent ACOG, "Screening for fetal," 2007; Angastiniotis & Modell, 1998; Davies et al., 2000 I Good A
2 A complete blood count and hemoglobin electrophoresis are the recommended tests to screen for hemoglobinopathies ACOG, "Screening for fetal," 2007 III Good B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-20. Screening for Domestic Abuse: Weeks 6 to 8

Recommendations

  1. Recommend routine screening for domestic abuse at the first visit, week 28, and the post partum visit, using the following three simple/direct questions: [B]
    • Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
    • Since you've been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
    • Within the last year, has anyone forced you to engage in sexual activities?
  2. There is insufficient evidence to recommend for or against specific interventions for identified domestic abuse in pregnancy. [I]
  3. If the screening is positive, follow appropriate medical/legal mandates for reporting requirements for state/branch of service. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine screening during pregnancy for domestic abuse Gazmararian et al., 1996 II-2 Fair B
2 Routine screening for domestic abuse with three simple/direct questions at weeks 8, 24, and 32, possibly using a computerized interview McFarlane et al., 1992; Renker & Tonkin, 2007 II-2 Fair B
3 Specific interventions after identifying domestic abuse in pregnancy McFarlane et al., 2000; Parker et al., 1999; Wathen & MacMillan, 2003 III Poor I

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-21. Screening for Depression: Weeks 6 to 8, 28, Postpartum Visit

Recommendations

  1. Women should be screened for depression during their first contact with obstetric healthcare services, at week 28, and at the postpartum visit. [B]
  2. Depression screening should be performed using a standardized screening tool such as the Edinburgh Postnatal Depression Scale (EPDS) or the 2-item Patient Health Questionnaire (PHQ-2). [B]
  3. Women should be asked early in pregnancy if they have had any previous psychiatric illnesses, and if they had a past history of serious psychiatric disorder they should be referred for a psychiatric assessment during the antenatal period. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Women are at increased risk for depressive disorders during pregnancy and postpartum periods Gaynes et al., 2005 I Good A
2 Depression screening improves detection during pregnancy and in postpartum Georgiopoulos et al., 1999; Gjerdingen & Yawn, 2007; National Institute for Health and Clinical Excellence (NICE), 2007 I Good A
3 PHQ-2 is a sensitive screen for depression in postpartum women Kroenke, Spitzer, & Williams, 2003 II, I Fair B
4 EPDS is a sensitive and valid screen for depression in the antepartum and postpartum period Adouard, Glangeaud-Freudenthal, & Golse, 2005; Boyd, Le, & Somberg, 2005; Evins, Theofrastous, & Galvin, 2000; Peindl, Wisner, & Hanusa, 2004; Hanusa et al., 2008 II Good B

EPDS, Edinburgh Postnatal Depression Scale; LE, level of evidence; PHQ-2, 2-item Patient Health Questionnaire; QE, quality of evidence; SR, strength of recommendation

First Visit With Provider (10 to 12 Weeks)

I-22. Establishing the Gestational Age: Weeks 10 to 12

Recommendations

  1. Establish the gestational age-based estimated delivery date (EDD) prior to 20 weeks' gestational age. [B]
  2. Various information and methods for dating a pregnancy may be available for consideration. EDD should be based on the most accurate information/method available for the individual pregnancy (see Table 4, "Accuracy of Pregnancy Dating Information/Modalities (Prioritized List)", in the original guideline. [B]
  3. Gestational age permitting, first-trimester ultrasound should be used to establish the gestational age and EDD if there is any uncertainty regarding the EDD due to: a pelvic examination discrepancy (> +/- two weeks), an unknown or uncertain last menstrual period (LMP), or irregular menstrual cycles. [B]
  4. When a first-trimester dating ultrasound has not been previously performed, a dating ultrasound at 16 to 22 weeks should be obtained. This examination can be combined with a basic screening anatomy ultrasound. [B]
  5. Situations with abnormal fetal biometric ratios (e.g., head/abdominal circumference [HC/AC], biparietal diameter/femur length [BPD/FL]) limit the accuracy of biometric measurements for pregnancy dating and may signal fetal anomalies or karyotype abnormalities. Such circumstances require individualized assessment by an advanced prenatal care provider to establish dating and recommend ongoing assessment(s) and management. [C]
  6. When clinical decisions late in pregnancy necessitate gestational age information and the dates have not been established prior to the 29th week, fetal maturity may be assumed when one of the following criteria are met: [C]
    • 20 weeks of audible fetal heart tones by a non-electronic method
    • 30 weeks of audible fetal heart tones by an electronic method
    • 36 weeks from a positive pregnancy test in a reliable laboratory

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Establish the gestational age-based due date (EDD) prior to 20 weeks' gestational age Mongelli & Gardosi, 1996; Wilcox et al., 1993 II Good B
2 Base the due date on the most accurate data available Mongelli & Gardosi, 1996; Peek et al., 1994 II Good B
3 Gestational age permitting, first-trimester ultrasound should be used to establish the gestational age if there is any uncertainty in the EDD Mongelli & Gardosi, 1996; Peek et al., 1994; Sladkevicius et al., 2005 II Good B
4 When a first-trimester dating ultrasound has not been previously performed, a dating ultrasound combined with an anatomy ultrasound at 16 to 22 weeks should be obtained Geirsson & Have, 1993; Gardosi, Vanner, & Francis, 1997; Mul, Mongelli, & Gardosi, 1996 II Good B
5 The presence of abnormal fetal biometric ratios limits the accuracy of biometric measurements for dating, may signal fetal anomalies, and requires individualized assessment by an advanced prenatal care provider Watson & McDonald, 2007; ACOG, "Ultrasonography," 2008 III Fair C
6 When clinical decisions late in pregnancy necessitate gestational age information and the dates have not been established, fetal maturity may be assumed based on well-established clinical grounds ACOG, 1999 III Fair C

EDD, estimated delivery date; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-23. Auscultation Fetal Heart Tones: Weeks 10 to 12; All Following Visits

Recommendations

  1. Recommend assessing fetal heart tones at each prenatal visit, starting at 10 to 12 weeks. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Auscultation of fetal heart tones Engstrom, 1985; Jimenez, Tyson, & Reisch, 1983; Working Group Consensus III Poor C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-24. Screening Fundal Height: Weeks 10 to 12; All Following Visits

Recommendations

  1. Recommend measuring fundal height in all pregnant women at each visit during the second and third trimesters. [B]
  2. There is insufficient evidence to recommend for or against measuring fundal height after 36 weeks' gestation. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Fundal height measurement at 20 to 36 weeks Calvert et al., 1982; Engstrom & Work, 1992; Jimenez, Tyson, & Reisch, 1983; Lindhard et al., 1990; Mathai, Jairaj, & Muthurathnam, 1987; Pearce & Campbell, 1987; Quaranta et al., 1981; Wise & Engstrom, 1985 I Good B
2 Fundal height measurement after 36 weeks Working Group Consensus III Poor I

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-25. Assessing (Inappropriate) Weight Gain: Weeks 10 to 12; All Following Visits

Recommendations

  1. Recommend assessing and documenting body mass index (BMI) of all pregnant women at the initial visit. [B]
  2. Pregnant women found to have a BMI <20 kg/m2 should be referred for nutrition counseling and considered at increased risk for fetal growth restriction. [B]
  3. Recommend screening for inappropriate weight gain for all women at every visit during pregnancy. [C]
  4. Pregnant women with inadequate weight gain at 28 weeks who are unresponsive to nutritional treatment need additional surveillance. Consider consultation/referral to advanced prenatal care provider. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine assessment of BMI at first visit Sebire et al., 2001 II-2 Fair B
2 Nutrition counseling for inadequate weight gain or initial BMI <20 kg/m2 Kramer, "Energy/protein," 2000; Kramer, "High protein," 2000; Sebire et al., 2001 II-2 Fair B
3 Routine screening for inappropriate weight gain at each visit Kelly et al., 1996 III Fair C
4 The practical evaluation of weight gain at 24 to 28 weeks Kelly et al., 1996 II-2 Fair C
5 Individualized weight gain based on pre-pregnancy weight Institute of Medicine (IOM), 1990 III Fair C

BMI, body mass index; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-26. Nutritional Supplements: Weeks 10 to 12

Recommendations

Multivitamins

  1. Multivitamin supplements should be taken one month preconceptually and should be continued through the first trimester. [C]
  2. Pregnant women taking nutritional supplements for a medical condition should continue that supplementation throughout pregnancy (e.g., B-12 with pernicious anemia and folate with seizure disorders). [I]
  3. Pregnant women on restrictive diets (vegetarians, bariatric surgery) should have nutrition consultation to customize vitamin supplementation regimen. [I]

Folate

  1. Folate supplements (400 mcg daily) should be taken one month preconceptually, continued through the first trimester and should be administered as part of the multivitamin supplementation. [A]
  2. Women who have delivered a child with an open neural tube defect (NTD) should supplement their diets with 4 mg folate daily for at least one month prior to conception and through the first trimester to reduce the risk of recurrence. [A]

Calcium

  1. Calcium supplementation may be considered to reduce the risk of preeclampsia in high-risk women and those with low baseline calcium intake. [A]

Omega 3

  1. There is insufficient evidence to support the use of Omega 3 supplements in the prevention of preterm birth, preeclampsia, and low birth weight. [I]
  2. Other dietary supplements should be used with caution and only after discussion with provider. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine vitamin supplementation during pregnancy Goh et al., 2007 I Fair B
Mahomed, "Folate," 2000; Mahomed, "Iron," 2000 III
Mahomed & Gulmezoglu, 2001; Mahomed & Gulmezoglu, 2000 III
2 Regular periconceptional multivitamin use Bodnar et al., 2006 II-2 Fair C
3 Routine calcium supplementation for high-risk and low dietary intake Hofmeyr, Atallah, & Duley, 2006 I Good A
4 Continuation of preconceptual vitamin supplements until the end of first trimester Werler et al., 1999 II-3 Good B
5 Continuation of preconceptual folate until the end of the first trimester Lumley et al., 2001 I Good A

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-27. Obesity: Weeks 10 to 12

Recommendations

  1. Recommend the following for obese pregnant women: [I]
    • Provision of specific information concerning maternal and fetal risks of obesity
    • Consideration of screening for gestational diabetes mellitus (GDM) on presentation or in the first trimester and repeated screening later in pregnancy if results are initially negative
    • Assessment and possible supplementation of vitamin B12, folate, iron, and calcium for women who have undergone bariatric surgery
    • Anesthesia consultation before labor
    • Possible use of graduated compression stockings, hydration, and early mobilization during and after cesarean section
    • Continuation of nutrition counseling and exercise program after delivery, and consultation with weight loss specialists before attempting another pregnancy.

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Recommendations for obese pregnant women ACOG, "Obesity," 2005 III Fair I

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-28. History of Gastric Bypass/Bariatric Surgery: Weeks 10 to 12

Recommendations

  1. Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary. [C]
  2. Women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and need for nutritional supplementation where indicated (e.g., Vitamin B12, folate, iron, and calcium). [C]
  3. Women who experience dumping syndrome should NOT be screened for gestational diabetes with a glucose load but rather with fasting and two-hour postprandial glucose values. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Women who have undergone bariatric surgery should be evaluated for nutritional deficiencies and may need vitamin supplementation Gurewitsch, Smith-Levitin, & Mack, 1996; Wax et al., 2007 II Poor C
2 Women with adjustable gastric bands should be monitored by their general surgeons during pregnancy ACOG, "Obesity," 2005
III Poor C
3 Women with dumping syndrome should not undergo diabetes screening with a glucose load Wax et al., 2007 III Poor C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-29. Screening for Gonorrhea: Weeks 10 to 12

Recommendations

  1. Recommend screening for gonorrhea in all pregnant women. [B]
  2. Pregnant women with positive cultures should be treated with ceftriaxone, per the CDC guidelines. [B]
  3. Pregnant women with positive screens for gonorrhea should be screened for other sexually transmitted diseases (STDs) and follow local mandatory reporting requirements. [I]
  4. Recommend performing a test of cure (TOC) during pregnancy after completing antibiotic therapy. TOC in pregnant women, unlike non-pregnant women, is recommended due to risk of complications resulting from persistent or recurrent infections. [I]
  5. Recommend counseling to decrease rate of reinfection. [C]
  6. Recommend referring the partner for testing and treatment, as appropriate. [C]
  7. Infected pregnant women must abstain from intercourse pending TOC. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine gonorrheal screening during pregnancy CDC, 1998 II-2 Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-30. Screening for Chlamydia: Weeks 10 to 12

Recommendations

  1. Recommend screening all pregnant women for Chlamydia trachomatis at the initial physical examination. [B]
  2. Pregnant women with positive cultures should be treated with azithromycin or erythromycin, per the CDC guidelines. [A]
  3. Pregnant women with positive screens for Chlamydia should be screened for other STDs. [I]
  4. Recommend performing a TOC during pregnancy after completing antibiotic therapy. TOC in pregnant women, unlike nonpregnant women, is recommended due to risk of complications resulting from persistent or recurrent infections. [C]
  5. Recommend counseling to decrease rate of re-infection. [C]
  6. Recommend referring partner for testing and treatment, as appropriate. [C]
  7. Infected pregnant women must abstain from intercourse pending TOC. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine screening for Chlamydia trachomatis at initial physical examination Hammerschlag et al., 1979 II-2 Fair B
2 Treatment per CDC guidelines for positive cultures Blackwell et al., 1993 II-2 Fair A
3 Screening for other STDs, if Chlamydia screen is positive Vuylsteke et al., 1993 II-2 Fair B
4 TOC after completion of antibiotic therapy Working Group Consensus III Poor C
5 Counseling to prevent reinfection Vuylsteke et al., 1993 II-2 Fair C

CDC, Centers for Disease Control and Prevention; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation; STD, sexually transmitted disease; TOC, test of cure

I-31. Screening for and Prevention of Cervical Cancer: Weeks 10 to 12

Recommendations

  1. Women current with routine screening for cervical cancer do not need to undergo additional testing. If the woman will come due for routine screening before the eight week postpartum visit, a screening test should be performed at the first prenatal visit. [B]
  2. For women who do not receive cervical cancer screening antenatally, screening should be considered at the eight-week postpartum visit to ensure compliance with routine cervical cancer screening guidelines. [B]
  3. Recommend performing cervical screening in pregnancy with a brush sampler and spatula. [A]
  4. Recommend women with abnormal cervical cytology during pregnancy be managed based on local algorithms, which may include repeat testing, observation, or colposcopy. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Screening cervical smear in pregnancy Lurain & Gallup, 1979 II-2 Good B
2 Method of cervical smears Hoffman et al., 1991; Koonings et al., 1992 I Good A
3 Management of abnormal cervical smears Wright et al., 2007 III Fair C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-32. Screening for Herpes Simplex Virus (HSV): Weeks 10 to 12 or Onset of Symptoms

Recommendations

  1. Routine HSV culture-based screening of pregnant patients is not recommended. [I]
  2. Symptomatic patients, those who are seropositive, or seronegative patients who have infected partners require further testing and counseling. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine HSV screening of pregnant patients is not recommended ACOG, "Viral hepatitis," 2007 III Poor I

HSV, herpes simplex virus; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-33. Counseling for Cystic Fibrosis Screening: Weeks 10 to 12

Recommendations

  1. Information about cystic fibrosis (CF) should be provided to all couples. [I]
  2. For couples who desire screening at <18 weeks' gestation, only one partner should initially be screened; if the screening is positive then the other partner should be screened. [I]
  3. Cystic fibrosis carrier screening should be offered to all couples who desire it. Informed consent should be obtained prior to testing. [I]
  4. Either sequential (testing one partner first) or concurrent (testing both partners simultaneously) carrier screening for cystic fibrosis is appropriate. The latter option may be preferred if there are time constraints for decisions regarding prenatal diagnostic testing or termination of the affected pregnancy. [I]
  5. Recommend genetic counseling for individuals with a family history of cystic fibrosis, or for individuals found to be carriers of two cystic fibrosis mutations who have not previously received a diagnosis of cystic fibrosis. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Counseling for cystic fibrosis screening Committee on Genetics, ACOG, 2005 III Poor I

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-34. Management of Depression during Pregnancy: When Diagnosed

Recommendations

  1. When antenatal depression symptoms are mild to moderate, consider referring patients for non-pharmacological treatment, such as interpersonal therapy (IPT). [A]
  2. When pharmacological treatment of depression is necessary during pregnancy, the potential risks of selective serotonin reuptake inhibitor (SSRI) exposure during pregnancy should be balanced with the potential risks of untreated depression on the mother and fetus. [B]
  3. Avoid paroxetine use during pregnancy when possible. Consider fetal echocardiography for women exposed to paroxetine during early pregnancy. [B]
  4. Choice of medications should be based on the well-characterized reproductive safety profiles of the medication, while also considering the severity of the depressive disorder and the wishes of the pregnant patient. [C]
  5. Multidisciplinary management of the pregnant patient with depression is recommended to the extent that it is possible. This may involve the patient's obstetrician, behavioral healthcare provider, primary care physician, and pediatrician. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Interpersonal psychotherapy (IPT) is an efficacious treatment for depression during pregnancy Adouard, Glangeaud-Freudenthal, & Golse, 2005; Bledsoe & Grote, 2006; Grote et al., 2004; Spinelli & Endicott, 2003; Spinelli, 1997 I Fair B
2 Light therapy is promising for treating depression during pregnancy, especially when affected by seasonal change Epperson et al., 2004 I Fair B
Oren et al., 2002 II
3 SSRI use prior to 20 weeks' gestation, with the exception of paroxetine, has not been shown to increase congenital malformations Einarson & Einarson, 2005 II-2 Fair B
4 SSRI use is associated with a neonatal withdrawal syndrome Levinson-Castiel et al., 2006 II-2 Fair C
5 SSRI use is associated with an increased rate of persistent pulmonary hypertension Chambers et al., 2006 II-2 Fair B
6 Behavioral therapy has benefit in postpartum depression   II-2 Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation; SSRI, selective serotonin reuptake inhibitor

I-35. Periodontal Disease and Dental Care: Weeks 10 to 12

Recommendations

  1. Assessment of oral health and instruction on maintaining a high level of oral hygiene should be offered to all pregnant women during their initial prenatal assessment to promote oral health and the general health of the woman. [C]
  2. Preventative dental treatment is safe and should be provided as early in pregnancy as possible. [B]
  3. Routine dental care, including x-rays and periodontal therapy, are effective and safe during pregnancy, and should be recommended. [B]
  4. There is insufficient evidence to recommend the routine treatment of periodontal disease in order to alter the rates of preterm delivery (PTD), low birth weight (LBW) or fetal growth restriction. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Provide dental screening and patient teaching on oral health during pregnancy at the first visit Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology, 2004 III Fair C
Dasanayake et al., 2008 II-2
New York State Dept of Health, 2006 III
2 Preventive dental services are safe in pregnant women and should be provided early in pregnancy to prevent oral disease Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology, 2004; American Dental Association Council on Scientific Affairs, 2006; New York State Dept of Health, 2006 II-2 Good B
3 Routine dental care, including x-rays and periodontal therapy, are effective and safe during pregnancy, and should be recommended New York State Dept of Health, 2006; Task Force on Periodontal Treatment of Pregnant Women, American Academy of Periodontology, 2004; American Dental Association Council on Scientific Affairs, 2006 II-2 Good B
4 Routine treatment of periodontal disease has not been proven to decrease rates of preterm birth, low birth weight or fetal growth restriction Michalowicz et al., 2006 I Good I
Xiong et al., 2006 II-2

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-36. Prenatal Screening for Fetal Chromosomal Abnormalities: Weeks 10 to 12; 16 to 20

Recommendations

  1. All pregnant women, regardless of age, should be offered a prenatal screening test for the most common clinically significant fetal anomalies as a routine part of prenatal care. [B]
  2. Women presenting for care at appropriate gestational ages should have aneuploidy screening and diagnostic options available to them that provide first-trimester results as well as strategies that provide second-trimester results. The specific first-trimester screening strategy made available by or in the institution must be decided prior to embarking upon that strategy. [B]
  3. Initial limited and comprehensive prescreen/pretest counseling methods may include written or multimedia communication, one-on-one, or group counseling formats. Post-test and late entry counseling should be provided in an individualized one-on-one format. [B]
  4. Screening programs should show respect for the needs and quality of life of the woman and her family. Counseling should be nondirective and should respect a woman's choice to accept or to refuse any or all of the testing or options offered at any point in the process. [I]
  5. The following modes of prenatal screening/diagnostic testing should be available for women receiving prenatal care in the DoD/VA: [B] (see Appendix E in the original guideline)
    • No test at all
    • Screening with results in first trimester
    • Screening with results in second trimester
    • Diagnostic/invasive test in first and second trimester
  6. In order to make these screening and diagnostic options available, each institution providing prenatal care should provide locally or arrange for access to: genetic counseling, first- and second-trimester serum marker assessment, first-trimester nuchal translucency (NT) measurement, basic and comprehensive second-trimester ultrasound assessment, first-trimester chorionic villus sampling and second-trimester amniocentesis. [I]
  7. All women considered high-risk, due to maternal age, personal or family history, or the result of a previous test, should be offered the choice of a first- or second-trimester screening strategy and the choice of first- or second-trimester diagnostic testing including appropriate comprehensive pre- and post-test genetic counseling. [I]
  8. A comprehensive ultrasound may be offered as a primary or follow-on screening test. [B]
  9. First-trimester NT should be interpreted for risk assessment only when performed by a trained sonographer who is accredited to provide this service [B] and when offered together with biochemical markers. [A]
  10. For women who undertake first-trimester screening (FTS), second-trimester serum alpha fetoprotein (AFP) screening and/or ultrasound examination should be offered to screen for open neural tube defects (ONTD). [B]
  11. Pregnant women with persistent unexplained elevations of maternal serum alpha fetoprotein (MSAFP) are at increased risk for adverse perinatal outcome and should receive specialized prenatal care. [B]
  12. The Quad Marker Screen should be used rather than the Triple Marker Screen when second-trimester serum screening is undertaken. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Offer multiple marker maternal serum analyte screening to all pregnant women at gestational ages between 15 and 20 weeks ACOG, "Screening for fetal," 2007; Haddow et al., 1992; Malone et al., 2005 II-1 Good B
2 Provide pre-test patient education and counseling Nadel et al., 1990; Dahl et al., 2006; Davey et al., 2005 II-2 Good B
3 Women at high-risk for fetal aneuploidy (age =35 at delivery or prior first child or fetus with aneuploidy) require genetic counseling Haddow et al., 1994 II-1 Good B
4 Screen-positive women require targeted ultrasound examination for risk modification and counseling prior to decision for invasive testing Smith-Bindman et al., 2001; ACOG, "Screening for fetal," 2007 II-1 Good B
5 Women with persistent unexplained elevations of maternal serum AFP are at increased risk for adverse prenatal outcome ACOG, "Screening for fetal," 2007; Dugoff et al., 2005 I Good A

AFP, alpha fetoprotein; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 All women, regardless of age, should be offered aneuploidy screening ACOG, "Screening for fetal," 2007 III Fair B
2 When discussing options with patients, providers should furnish information on detection and false positive rates, advantages and disadvantages of each testing method ACOG, "Screening for fetal," 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 Hunter et al., 2005; Fries, Bashford, & Nunes, 2005 I Fair B
4 First-trimester screening can lead to a diagnosis of fetal aneuploidy much earlier ACOG, "Screening for fetal," 2007; Malone et al., 2003; Malone et al., 2005; Wapner et al., 2003; Wald et al., 2003 I Good A
5 Measurement of nuchal translucency alone is less effective for first-trimester screening than is the combined test (nuchal translucency measurement and biochemical markers) Nicolaides, 2004; Snijders et al., 2002 II-2 Fair B
6 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 & Gray, 1999; Nicolaides et al., 1992 II Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-37. Obstetric Ultrasound: Week 16-20

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 sonographically detectable maternal or fetal abnormality where an intervention may improve the outcome (See table 5 in the original guideline 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 should be performed and interpreted by qualified healthcare providers. [A]

(See Practice Guideline for the Performance of Antepartum Obstetrical Ultrasound Examinations at: http://www.aium.org/publications/guidelines/obstetric.pdf External Web Site Policy)

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Counsel and educate prior to scheduling sonographic study Chervenak & McCullough, 1992; Working Group Consensus III Fair 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 Watson & McDonald, 2007; ACOG, "Ultrasonography," 2008; Mongelli & Gardosi, 1996; Wilcox et al., 1993 I Good B
3 Use ultrasound to evaluate/diagnose women who are at increased risk of sonographically detectable maternal or fetal complications or uncertainty regarding gestational age or fetal health   III Good B
4 Complete obstetric sonographic examination for all consenting low-risk women Society of Obstetricians and Gynecologists of Canada (SOGC), 1999; Working Group Consensus III Poor I
5 Complete obstetric sonographic studies performed and interpreted by qualified healthcare providers Crane et al., 1994 I Good A

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-38. Education about Symptoms of Preterm Labor: Week 24

Recommendations

  1. Pregnant women should be educated about the most common symptoms of preterm labor:
    • Low, dull backache
    • Four or more uterine contractions per hour. Uterine contractions may be perceived by the patient as:
      • Menstrual-like cramps
      • Sensation of the "baby rolling up in a ball"
      • Increased uterine activity compared to previous patterns
      • Abdominal cramping (may be associated with diarrhea)
    • Increased pelvic pressure (may be associated with thigh cramps)
    • Change in vaginal discharge such as change in color of mucus, leaking of clear fluid, spotting or bleeding or discharge associated with itching or fish-like odor immediately after intercourse
    • General sensation that "something feels different" (e.g., agitation, flu-like syndrome, and sensation that baby has "dropped").
  2. A pregnant woman who experiences any of the above symptoms or is unsure about the presence of any of the above should lie down on her side with one of her hands on her lower abdomen to palpate for uterine contractions for an additional hour. If symptoms persist and/or she palpates four or more uterine contractions in the hour, she should seek immediate medical care. The exception to this is the pregnant woman who notes the presence of vaginal bleeding, leaking of clear fluid from the vagina, or a vaginal discharge with a fish-like odor immediately after intercourse, all of which should prompt immediate medical attention. [I]
  3. Re-emphasize to the pregnant woman that she is the most important link in the early diagnosis of preterm labor, and that early diagnosis and treatment of preterm labor increases the chances for a healthy infant.
  4. Educate the pregnant woman that she can safely continue moderate exercise and activity during her pregnancy so long as she does not notice any of the symptoms of preterm labor. The exception to this is that she may notice some increase in uterine cramping with moderate exercise or activity. This is of no consequence so long as the cramping ceases when she stops her activity. She should limit her activity to no more than two hours per session. [B]
  5. Women with uncomplicated pregnancies may continue a standard work schedule throughout their pregnancy. If their work is strenuous or they spend long periods of time on their feet they should limit their work week to 40 hours and workday to eight hours during the last trimester (beginning at 28 weeks) or sooner if they frequently experience symptoms of preterm labor while at work. Pregnant women should attempt to limit periods of time on their feet to three hours. [B]
  6. There is no evidence that sexual intercourse increases the probability of preterm labor in women with uncomplicated pregnancy. They may experience some uterine contractions following orgasm; however, this is a normal response and she only needs to seek medical attention if they persist at four or more per hour for at least three hours, or if vaginal bleeding or spotting is noted.

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Educate about the common symptoms of preterm labor Herron, Katz, & Creasy, 1982; Katz, Goodyear, & Creasy, 1990; Morrison, 1990; Ross et al., 1986 II-2 Good A
2 Perform intensive self-assessment if unsure about the presence of preterm labor symptoms prior to self-referral Working Group Consensus III Poor I
3 Educate the pregnant woman that she is a vital link in the early detection and treatment of preterm labor Herron, Katz, & Creasy, 1982; Katz, Goodyear, & Creasy, 1990 II-2 Good B
4 A regular, moderate exercise program does not increase the risk for preterm labor See section I-3, "Exercise During Pregnancy" II-1 Good B
5 Physically demanding labor/work and prolonged standing increase risk for preterm birth, hypertension, and preeclampsia AAP/ACOG, 1998; Gabbe & Turner, 1997; Luke et al., 1995; Mozurkewich et al., 2000; Teitelman et al., 1990 II-2 Good B
6 Coitus is not associated with an increased risk for preterm labor Read & Klebanoff, 1993 II-2 Good A

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-39. Counseling for Trial of Labor: Week 24

Recommendations

  1. Appropriate candidates for a trial of labor include women with one prior low transverse cesarean and no other contraindications to labor or vaginal delivery. Women with two prior low transverse cesareans are candidates provided they have undergone a previous vaginal delivery. [B]
  2. Women who meet the criteria for a possible trial of labor should be counseled regarding the risks and benefits of vaginal birth after cesarean delivery (VBAC) versus repeat low transverse cesarean delivery. Ideally, informed consent should be documented in the antepartum period after 24 weeks, and again at the time of admission for delivery.
  3. There is insufficient evidence to recommend for or against cesarean delivery on maternal request. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Appropriate candidates for trial of labor ACOG Practice Bulletin #54, 2004 ,III Good B
2 Counseling for trial of labor should be performed twice during pregnancy ACOG Practice Bulletin #54, 2004; Working Group Consensus III Poor I
3 Perform cesarean delivery on maternal request (recommend neither for nor against)   I Fair I
NIH State-of-the-Science, 2006 II Poor

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-40. Screening for Gestational Diabetes: Week 28

Recommendations

  1. Recommend screening all pregnant women for GDM at 24 to 28 weeks' gestation. [B]
  2. Screening for GDM should be performed by randomly administering a 50 gram oral glucose tolerance test (GTT) followed by a blood draw one hour later. Generally accepted threshold values of the 1-hour screen are between 130 mg/dL and 140 mg/dL. Pregnant women who are positive require the diagnostic three-hour GTT. [B]
  3. In the three-hour GTT a 100-gram glucose load is administered to a woman who has fasted overnight (minimum eight hours). Blood draws are performed fasting and at one, two and three hours after the oral glucose load. No special diet is required before this test. [C]
  4. Two acceptable sets of threshold values for the three-hour 100-gram GTT can be used to diagnose gestational diabetes: the National Diabetes Data Group (NDDG) criteria and the Carpenter/Coustan conversion criteria. Institutions should adopt one of these two criteria sets based upon their population demographics. There should NOT be variance within the facility itself, though variance may occur between facilities. [B]
  5. For patients with only one abnormal value, consider one of the following: [C]
    • Undergo a repeat three-hour 100-gram glucose challenge test approximately one month following the initial test
    • Have dietary management and intermittent postprandial glucose testing performed in a manner similar to women with gestational diabetes.
  6. Patients with a history of gastric bypass surgery may experience a "dumping" syndrome following ingestion of large quantities of simple sugar. An alternative to the 50-gram glucose tolerance test in these patients includes a fasting and two-hour postprandial finger sticks for one week. Target ranges are 90 mg/dL or lower fasting and 120 mg/dL or lower for postprandial. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Perform a routine screening for GDM at 24 to 28 weeks with a random one-hour 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 one-hour 50-gram glucose challenge ACOG, 2000 II-1 Good B
Naylor et al., 1997 II-3
4 All pregnant women with a one-hour positive test require a three-hour GTT ACOG, 2000 III Fair B
5 Acceptable sets of threshold values for the three-hour 100 gram glucose challenge ACOG, 2000; "Report of the Expert Committee," 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, 2000 I Fair C
Langer et al., 1987 II-2
Lindsay, Graves, & Klein, 1989 II-2
7 A high-carbohydrate diet before oral GTT is not necessary in normally nourished pregnant women Buhling et al., 2004; Crowe, Mastrobattista, & Monga, 2000; Entrekin, Work, & Owen, 1998 II-1 Poor C
8 Patients with history of gastric bypass may not tolerate the 50-gram GTT; alternative is a fasting and two-hour postprandial finger sticks Burt, 2005 III Poor C

GDM, gestational diabetes mellitus; GTT, glucose tolerance test; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-41. Iron Supplement: Week 28

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]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine iron supplementation Pena-Rosas & Viteri, 2006 II-3 Poor I
Ziaei et al., 2007 I
2 Selective iron supplementation Hemminki & Rimpela, 1991; Reveiz, Gyte, & Cuervo, 2007 I Good B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-42. Anti-D Prophylaxis for Rh-Negative Pregnant Women: Week 28

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. Recommend using either 300 mcg of anti-D immunoglobulin at 28 weeks or 100 mcg of anti-D immunoglobulin at 28 and 34 weeks' gestation. [I]
  4. 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]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Anti-D prophylaxis for unsensitized D-negative pregnant women Crowther & Keirse, 2000; Urbaniak, 1998 I Fair B
2 Middle cerebral artery Doppler ultrasonograph for women who demonstrate evidence of isoimmunization or with a history of a prior hydropic infant ACOG, "Management," 2006 I Good A

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-43. Assess for Preterm Labor: Weeks 28, 32

Recommendations

  1. Pregnant women should be educated about the most common symptoms of preterm labor:
    • Low, dull backache
    • Four or more uterine contractions per hour. Uterine contractions may be perceived by the patient as:
      • Menstrual-like cramps
      • Sensation of the "baby rolling up in a ball"
      • Increased uterine activity compared to previous patterns
      • Abdominal cramping (may be associated with diarrhea)
    • Increased pelvic pressure (may be associated with thigh cramps)
    • Change in vaginal discharge such as change in color of mucus, leaking of clear fluid, spotting or bleeding or discharge associated with itching or fish-like odor immediately after intercourse.
    • Sensation that "something feels different" (e.g., agitation, flu-like syndrome, and sensation that baby has "dropped").
  1. A pregnant woman who experiences any of the above symptoms or is unsure about the presence of any of the above should lie down on her side with one of her hands on her lower abdomen to palpate for uterine contractions for an additional hour. If symptoms persist or she palpates four or more uterine contractions in the hour, she should seek immediate medical care. The exception to this is the pregnant woman who notes the presence of vaginal bleeding, leaking of clear fluid from the vagina or a vaginal discharge with a fish-like odor immediately after intercourse, all of which should prompt immediate medical attention.
  2. If no diagnosis of preterm labor is established, continuation in the guideline is appropriate.

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Educate the pregnant woman that she is a vital link in the early detection and treatment of preterm labor Herron, Katz, & Creasy, 1982; Katz, Goodyear, Creasy, 1990 II-2 Good B
2 Perform intensive self-assessment if unsure about the presence of preterm labor symptoms prior to self-referral Working Group Consensus III Poor I

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-44. Daily Fetal Movements Counts: Weeks 28; All Following Visits

Recommendations

  1. Recommend instructing all pregnant women about the importance of assessing fetal movement on a daily basis beginning in the third trimester. [B]
  2. Recommend instructing all pregnant women as to the course of action they should take if they do not perceive the minimum fetal movement counts within the time frame specific to their healthcare facility. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Instruct all pregnant women to assess fetal movement on a daily basis beginning in the third trimester Moore & Piacquadio, 1989; Neldam, 1980 II-2 Good B
2 Instruct all pregnant women as to the course of action they should take if they do not perceive the minimum fetal movement counts within the time frame specific to their healthcare facility Moore & Piacquadio, 1989; Neldam, 1980; Pearson & Weaver, 1976; Sadovsky & Yaffe, 1973 II-2 Good B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-45. Counseling for Family Planning: Week 32

Recommendations

  1. Recommend antepartum counseling and educating all pregnant women regarding family planning, to include various temporary contraceptive means and/or permanent sterilization. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Antepartum counseling for family planning Pati & Cullins, 2000 III Poor C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-46. Screening for Group B Streptococcus (GBS): Week 36

Recommendations

  1. Recommend screening all pregnant women for Group B streptococcus (GBS) at 35 to 37 weeks' gestation, using a rectovaginal culture and selective broth media to identify colonized women. [B]
  2. Screening should be repeated every four weeks until delivery. [C]
  3. Pregnant women with positive rectovaginal cultures should be treated with intrapartum intravenous (IV) chemoprophylaxis with either penicillin or ampicillin (if no contraindications)*. [A]
  4. Pregnant women who have had a previous child with early-onset GBS infection or have GBS bacteriuria in the current pregnancy should receive intrapartum antibiotics, without screening cultures. [A]

*Management of the GBS-colonized parturient with a history of an allergic reaction to penicillin agents: due to emerging resistance to previous second-line antimicrobial agents, clindamycin and erythromycin (10 to 15 percent resistant strains in most centers), alternative second-line agents for women with a history of allergic reactions to penicillin or ampicillin are listed below:

  • Administer cefazolin 2 gm IV load, followed by 1 gm IV every eight hours, for allergic reaction other than immediate hypersensitivity
  • Administer vancomycin 1 gm IV load, followed by 1 gm IV every 12 hours, for immediate hypersensitivity reaction (anaphylaxis, dyspnea, rapid onset of urticarial rash).

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Pregnant women should be screened for GBS at 35 to 37 weeks' gestation using a rectovaginal culture and selective broth media to identify colonized women ACOG, 2002; CDC, 2002; Main & Slagle, 2000 II-1 Good B
2 Treat positive rectovaginal cultures with intrapartum IV chemoprophylaxis with either penicillin or ampicillin ACOG, 2002; CDC, 2002; Main & Slagle, 2000; Smaill, 2001 I Good A
3 Women who have had a previous child with early-onset GBS infection or GBS bacteriuria in the current pregnancy should receive intrapartum antibiotics, without screening cultures ACOG, 2002; CDC, 2002 II-1 Good A
4 Pregnant women presenting in labor <37 weeks' gestation should receive intrapartum IV chemoprophylaxis ACOG 2002; Boyer & Gotoff, 1986; CDC, 2002 II-1 Good A
5 For women in labor at term with unknown culture status, administer IAP if the duration of membrane rupture ≥18 hours or maternal temperature ≥100.4°F (38°C) ACOG, 2002; CDC, 2002 II-1 Fair B
6 Prophylactic antibiotics should be administered at least two hours prior to delivery, when possible* de Cueto et al., 1998; Lin et al., 2001 II-2 Good B
7 Women undergoing scheduled cesarean delivery prior to the onset of labor with intact membranes do not require prophylactic antibiotics, unless they have had a previous child with early-onset GBS infection Hager et al., 2000 III Fair C

*Management of the parturient anticipated to deliver imminently following admission: as it is difficult to anticipate accurately when a woman will deliver, women identified as candidates for IAP should receive prophylactic antibiotics regardless of the interval between admission and delivery as vertical transmission rates have been shown to have a clinically and statistically significant decrease within two hours of maternal administration. Thus, withholding of IAP from women solely on the basis of anticipated admission-delivery interval should be discouraged.

GBS, Group B streptococcus; IAP, intrapartum antibiotics for prophylaxis; IV, intravenous; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-47. Assessment of Fetal Presentation: Weeks 36, 38-41

Recommendations

  1. Recommend screening for non-cephalic presentation for all patients at 36 weeks' gestation. [B]
  2. There is insufficient evidence to recommend for or against Leopolds versus cervical exam as the best screening method to determine fetal presentation. [I]
  3. Recommend ultrasound for confirmation, if non-cephalic presentation is suspected. [B]
  4. If non-cephalic presentation is confirmed and there are no contraindications, recommend external cephalic version at 37 weeks or beyond and referral to an advanced prenatal care provider. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Screening for non-cephalic presentation at 36 weeks' gestation Hofmeyr & Hannah, 2001 II-2 Fair B
2 Leopolds versus cervical exam for determining fetal presentation Lydon-Rochelle et al., 1993; Thorp, Jenkins, & Watson, 1991 II-2 Fair I
3 Ultrasound for presentation confirmation Thorp, Jenkins, & Watson, 1991 II-2 Good B
4 External cephalic version at 37 weeks or beyond, if there are no contraindications Hofmeyr & Kulier, "Cephalic version," 2000; Hofmeyr & Kulier, "External cephalic version," 2000 I Good B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

Visits During Weeks: 38-41

I-48. Consider Weekly Cervical Check/Stripping (Sweeping): Weeks 38-41

Recommendations

  1. Consider offering routine membrane sweeping to all pregnant women every visit beginning at 38 weeks. [C]
  2. There is insufficient data to encourage or discourage this practice in women known to be GBS-colonized. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Membrane stripping at each visit beginning at 38 weeks Boulvain, Stan, & Irion, 2005 I Fair C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-49. Term Management: Weeks 38-41

Recommendations

  1. In the absence of contraindications, labor induction should be offered to women who reach 41 and 0/7 weeks undelivered. [A]
  2. In those patients with a favorable cervix (Bishop score > 6), induction after 39 weeks may be considered. [B]
  3. When labor induction is offered or planned, women should be educated on the risks of induction, including length of induction, discomfort involved, and the process in determining appropriate timing of induction. [B]
  4. Antepartum fetal testing should begin as soon as possible after 41 and 0/7 weeks if not scheduled for induction at this time. [C]
  5. Testing should consist of weekly amniotic fluid assessment and twice weekly non-stress testing (NST). [C]
  6. Inadequate amniotic fluid index should prompt further evaluation to determine the need for delivery. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Inducing at 41 weeks reduced C-section Heimstad, Romundstad, & Salvesen, 2008; Sanchez-Ramos et al., 2003 I Good A
2 Induction after 39 weeks with favorable cervix Nielsen et al., 2005 I Fair B
3 Unrealistic expectations regarding induction length and pain leads to decreased patient satisfaction Shetty et al., 2005 II-2 Fair B
4 Antepartum fetal testing beginning at 41 weeks Guidetti, Divon, & Langer, 1989; Rosen et al., 1995 I Good A
5 Antepartum testing should consist of weekly AFI and biweekly NST ACOG, 1999 III Fair C
6 Abnormal testing may indicate fetal compromise and should prompt further surveillance or delivery Chamberlain et al., 1984; Manning et al., 1993; Rutherford et al., 1987 II-2 Fair B

AFI, amniotic fluid index; LE, level of evidence; NST, non-stress testing; QE, quality of evidence; SR, strength of recommendation

I-50. Immunization HPV Vaccine: Prior to Discharge; Postpartum Visit

Recommendations

  1. Offer vaccination before postpartum discharge to all women ≤26 years of age who have not previously completed human papillomavirus (HPV) vaccination series. [B]
  2. Women who begin their HPV vaccination series in the immediate postpartum period should complete the series with subsequent vaccinations at two months and six months following the first injection in the series. The eight-week postpartum visit provides an opportunity for the second injection. [C]
  3. Vaccination to protect against HPV in individuals with a history of dysplasia is controversial and the decision to proceed in this situation should be made between a patient and her provider. [I]
  4. Women who have initiated the HPV vaccine series before becoming pregnant should halt the series during pregnancy, and resume after delivery. [I]
  5. HPV vaccination may be given to lactating women. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 HPV vaccine reduces the incidence of cervical intraepithelial neoplasia and cervical cancer Brison et al., 2007 II-2 Good B
2 Report to Congress: Prevention of Genital Human Papillomavirus Infection   III Poor I

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-51. Education - Shaken Baby Syndrome (SBS): At Discharge; Postpartum Visit

Recommendations

  1. All pregnant women and fathers should receive education about Shaken Baby Syndrome prior to discharge from the hospital. [I]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Use of comprehensive parent education program decreases incidence of abusive head injury Dias et al., 2005 II Fair B
2 SBS prevention kits are customized and validated as tools for military families National Center on Shaken Baby Syndrome (http://www.dontshake.org External Web Site Policy) III Poor C

LE, level of evidence; QE, quality of evidence; SBS, Shaken Baby Syndrome; SR, strength of recommendation

Interventions Not Recommended in Prenatal Care (All Weeks)

I-52. Routine Screening with Fetal Fibronectin: Not Recommended

Recommendations

  1. Recommend against routine screening for preterm birth with fetal fibronectin (fFN) test. [D]
  2. Utilization of fFN testing in symptomatic women between 24 and 34 6/7 weeks' gestation may be useful in guiding management of women with signs and symptoms of preterm labor. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine fFN at 24 weeks' estimated gestational age for prevention of preterm labor (not recommended) Ramsey & Andrews, 2003; Goldenberg et al., 1996; Honest et al., 2002; Leitech et al., 1999; Revah, Hannah, & Sue-A-Quan, 1998; Tekesin et al., 2005 I Good D
2 Utilization of the fFN test in symptomatic women between 24 and 34 weeks' gestation may be useful in guiding management of women with preterm contractions ACOG Committee on Practice Bulletins-Obstetrics, 2003; Honest et al., 2002; Tekesin et al., 2005 II-2 Fair B

fFN, fetal fibronectin; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-53. Routine Cervical Examination: Not Recommended

Recommendations

  1. Recommend against performing cervical examination to screen for preterm birth prevention in low-risk asymptomatic pregnant women. [D]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine cervical examination at 28 weeks' gestation for prevention of preterm labor (not recommended) Buekens et al., 1994 I Good D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-54. Routine Antenatal Pelvimetry: Not Recommended

Recommendations

  1. Recommend against the use of antenatal pelvimetry (clinical or radiographic) in routine prenatal care. [D]
  2. There is fair evidence that clinical pelvimetry is not effective in predicting the actual occurrence of cephalopelvic disproportion (CPD), and its performance is associated with significant increase in cesarean section rates. [D]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine clinical pelvimetry for estimation of adequacy for trial of labor (not recommended) Pattinson, 2000 I Fair D
2 X-ray pelvimetry may be harmful (not recommended) Pattinson, 2000 I Fair D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-55. Routine Urine Dipstick Test: Not Recommended

Recommendations

  1. Recommend against the use of urine dipstick testing for protein and glucose during prenatal visits (the appropriate screening test for gestational diabetes is the one-hour glucola). [D]
  2. Recommend the use of selective laboratory urinalysis for pregnant women with signs or symptoms of preeclampsia. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine urine dipstick testing (not recommended) Kuo, Koumantakis, & Gallery, 1992 II-2 Fair D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-56. Routine Edema Evaluation: Not Recommended

Recommendations

  1. Recommend against routine evaluation for edema in pregnancy. [D]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine evaluation for edema in pregnancy (not recommended) ACOG Technical Bulletin, 1996; Kent et al., 1999; Young & Jewell, 2000 II-1 Fair D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-57. Routine Screening for Cytomegalovirus (CMV): Not Recommended

Recommendations

  1. The evidence is insufficient to recommend for or against routine screening for cytomegalovirus. [I]
  2. Recommend counseling pregnant women about methods to prevent acquisition of CMV during pregnancy. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine testing of pregnant women for CMV (not recommended) Working Group Consensus III Poor I
2 Counseling of day care workers on good hand washing Working Group Consensus III Poor C

CMV, cytomegalovirus; LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-58. Routine Screening for Parvovirus: Not Recommended

Recommendations

  1. Recommend against routine testing for parvovirus in pregnancy. [D]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine testing for parvovirus (not recommended) Guidozzi, Ballot, & Rothberg, 1994 II-3 Fair D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-59. Routine Screening for Toxoplasmosis: Not Recommended

Recommendations

  1. Recommend against routine testing for toxoplasmosis in pregnancy. [D]
  2. Recommend counseling pregnant women about methods to prevent acquisition of toxoplasmosis during pregnancy. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine screening for toxoplasmosis (not recommended) Frenkel, 1995 I-3 Fair D
Wallon et al., 1999 I
Wong & Remington, 1994 II-3
2 Educate about prevention Working Group Consensus III Poor C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-60. Routine Screening for Bacterial Vaginosis: Not Recommended

Recommendations

  1. Recommend against routine screening for bacterial vaginosis in asymptomatic pregnant women. [D]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine screening for bacterial vaginosis (not recommended) Leitich et al., 2003; McDonald, Brocklehurst, & Gordon, 2007; Riggs & Klebanoff, 2004; Varma & Gupta, 2006; USPSTF, 2008 I Good D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-61. Immunization – MMR: (Measles/Mumps/Rubella) Not Recommended

Recommendations

  1. Recommend against routine measles/mumps/rubella (MMR) immunization during pregnancy. [D]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine administration of MMR during pregnancy (not recommended) Krogh et al., 1989 II-2 Poor D

LE, level of evidence; MMR, measles/mumps/rubella; QE, quality of evidence; SR, strength of recommendation

I-62. Routine Immunization – Varicella: Not Recommended

Recommendations

  1. Recommend against routine varicella vaccination in pregnancy. [D]
  2. Recommend serological testing early in pregnancy for all pregnant women with a negative or uncertain history. [B]
  3. Recommend offering vaccination postpartum to pregnant women who are non-immune. [B]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine varicella vaccination in pregnancy (not recommended) Smith et al., 1998 II-2 Poor D
2 Serological testing early in pregnancy for pregnant women with a negative or uncertain history Smith et al., 1998 II-2 Poor B
3 Postpartum varicella immunization AAP, 1998 III Fair B

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-63. Routine Ultrasound Evaluation of Cervical Length: Not Recommended

Recommendations

  1. Recommend against routine cervical length screening at 24 weeks' gestation. [D]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine cervical length screening at 24 weeks' gestation (not recommended) Doyle & Monga, 2004; Grimes-Dennis & Berghella, 2007; Heath et al., 2000; Hibbard et al., 1998; Hibbard, Tart, & Moawad, 2000; Honest et al., 2003; Iams, Goldsmith, & Weiss, 2001; Iams et al., 1996; Taipale & Hiilesmaa, 1998; Williams & Iams, 2004

II-2 Fair D

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-64. Repeat Screening for Anemia, Syphilis, and Isoimmunization: Not Recommended

Recommendations

  1. Recommend against routine repeat screening for blood group antibodies. [D]
  2. Recommend against routine repeat screening for anemia and syphilis. [D]
  3. Recommend providers consider repeat testing for anemia or syphilis at 24 to 28 weeks for women who are at higher risk for these conditions. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Repeat antibody screening (not recommended) Davis & Abbott, 1986 II-2 Fair D
2 Repeat anemia and syphilis screening (not recommended) Working Group Consensus III Poor D
3 Repeat anemia and syphilis screening for high-risk pregnant women Working Group Consensus III Poor C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

I-65. Routine Screening for Hypothyroidism: Not Recommended

Recommendations

  1. Recommend against routine screening for thyroid hormone status of the mother. [D]
  2. Recommend ensuring adequate iodine intake during pregnancy for pregnant women in areas of the country with questionable levels of dietary iodine. [C]

Evidence Table

  Recommendations Source of Evidence LE QE SR
1 Routine screening for thyroid deficiency (not recommended) Escobar, Jesus Obregon, & Escobar del Rey, 2000; Haddow et al., 1999; Pop et al., 1995 III Poor D
2 Adequacy of nutritional iodine Utiger, 1999 III Poor C

LE, level of evidence; QE, quality of evidence; SR, strength of recommendation

Definitions:

Quality of Evidence

I At least one properly done randomized controlled trial (RCT)
II-1 Well-designed controlled trial without randomization
II-2 Well-designed cohort or case-control analytic study, preferably from more than one source
II-3 Multiple time series evidence with/without intervention, dramatic results of uncontrolled experiment
III Opinion of respected authorities, descriptive studies, case reports, and expert committees

Overall Quality

Good High grade evidence (I or II-1) directly linked to health outcome
Fair High grade evidence (I or II-1) linked to intermediate outcome;
or
Moderate grade evidence (II-2 or II-3) directly linked to health outcome
Poor Level III evidence or no linkage of evidence to health outcome

Net Effect of the Intervention

Substantial More than a small relative impact on a frequent condition with a substantial burden of suffering, or
A large impact on an infrequent condition with a significant impact on the individual patient level
Moderate A small relative impact on a frequent condition with a substantial burden of suffering, or
A moderate impact on an infrequent condition with a significant impact on the individual patient level
Small A negligible relative impact on a frequent condition with a substantial burden of suffering, or
A small impact on an infrequent condition with a significant impact on the individual patient level
Zero or Negative Negative impact on patients, or
No relative impact on either a frequent condition with a substantial burden of suffering, or an infrequent condition with a significant impact on the individual patient level

Final Grade of Recommendation

  The net benefit of the intervention 
Quality of Evidence Substantial Moderate Small Zero or
Negative
Good A B C D
Fair B B C D
Poor I I I I

Evidence Rating System

A A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves important health outcomes and concludes that benefits substantially outweigh harm.
B A recommendation that clinicians provide (the service) to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and concludes that benefits outweigh harm.
C No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients.
At least fair evidence was found that the intervention is ineffective or that harms outweigh benefits.
I The conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention.
Evidence that the intervention is effective is lacking, or poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Clinical Algorithm(s)

Algorithms are provided in the original guideline document for:

  • Management of pregnancy
  • Prenatal screening for fetal chromosomal abnormalities (Appendix E)

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

Recommendations were based on evidence published in the medical literature. Where existing literature was ambiguous or conflicting, or where scientific data was lacking on an issue, recommendations were based on the clinical experience of the Working Group.

The quality of the evidence supporting individual recommendations is given for selected recommendations (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved management of pregnancy

Potential Harms

Potential harms of the prenatal aneuploidy screening and testing:

  • The prevalence in the population for fetal aneuploidy in the second trimester is small, resulting in relatively high false positive screening test results.
  • The great majority of women who have abnormal screening tests will ultimately deliver normal babies (>95%).
  • False positive tests occur in five percent of the overall population and in 20 percent or more of women over 35 years old. False positive tests cause maternal/familial anxiety and unnecessary procedures. The likelihood of having a normal baby when the screening tests are abnormal is approximately 95 percent.
  • Unnecessary diagnostic tests, in the case of false positive screening testing, can result in complications leading to the delivery of a previable fetus or fetuses resulting in fetal wastage/pregnancy loss.
  • Ongoing maternal/family anxiety in the case of an abnormal screening test, particularly when the woman declines to undergo diagnostic testing, can have a significant negative impact for the duration of the pregnancy and beyond.

Contraindications

Contraindications
  • Contraindications to tetanus-diphtheria (Td) booster include previous severe reaction such as anaphylaxis, generalized urticaria, or angioedema.
  • Paroxetine should be avoided during pregnancy when possible.

Qualifying Statements

Qualifying Statements
  • The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based on the best information available at the time of publication. They are designed to provide information and assist decision-making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management.
  • Variations in practice will inevitably and appropriately occur when providers take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation.
  • The recommendations in this guideline may be modified according to local practice conditions and updated scientific evidence. Except in very unusual circumstances, the recommendations outlined in this guideline should serve as a backbone to the supplemental prenatal care that is provided or recommended by advanced prenatal care providers.
  • The guideline and algorithms are designed to be adapted by individual facilities, considering needs and resources. The algorithm will serve as a guide that providers can use to determine best interventions and timing of care to optimize quality of care and clinical outcomes for their patients. This should not prevent providers from using their own clinical expertise in the care of an individual patient. Guideline recommendations are intended to support clinical decision-making but should never replace sound clinical judgment.

Implementation of the Guideline

Description of Implementation Strategy
  • The guideline and algorithms are designed to be adapted to individual facility needs and resources. The algorithm will serve as a guide that providers can use to determine best interventions and timing of care for their patients to optimize quality of care and clinical outcomes. This should not prevent providers from using their own clinical expertise in the care of an individual patient. Guideline recommendations are intended to support clinical decision-making but should never replace sound clinical judgment.
  • Although this guideline represents the state-of-the-art practice at the time of its publication, medical practice is evolving and this evolution will require continuous updating of published information. New technology and more research will improve patient care in the future. The clinical practice guideline can assist in identifying priority areas for research and optimal allocation of resources. Future studies examining the impact of this clinical practice guideline may lead to the development of new practice-based evidence.
Implementation Tools
Chart Documentation/Checklists/Forms
Clinical Algorithm
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
Department of Veteran Affairs, Department of Defense. VA/DoD clinical practice guideline for management of pregnancy. Washington (DC): Department of Veteran Affairs, Department of Defense; 2009. 163 p.
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2002 Oct (revised 2009)
Guideline Developer(s)
Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

Guideline Update Working Group

Composition of Group That Authored the Guideline

Working Group Members (VA): Gwen Garmon (Co-Chair), MD, MS; Connie La Rosa, RN, BSN, MSA; Patricia M. Hayes, PhD; Carla Cassidy, RN, MSN, NP

Working Group Members (DoD): Susan C. Altenburg, RN, BSN, MS, CNM; Susan Farrar, LCDR, MD, MPH, MC, USN; Bardett Fausett (Co-Chair), Lt Col, MC, USAF; Trisha Farrell, CDR, CNM, WHNP, NC, USN; Nancy Hughes, COL, CNM, USA; Ann Hryshko-Mullen, Lt Col, Ph.D, ABPP, USAF; Hathryn Kanzler Apolonioo, Capt, Psy.D; Mary Kreuger, MAJ, DO, MPH, USA; Len Kuskowski, CDR, MD, FACOG, MC, USN; Jason Pates, MAJ, MD, MC, USA; Mary Wahl, Lt Col, CNM, MSN, NC, USAF

Facilitator: Oded Susskind, MPH

Quality Management Division, MEDCOM: Ernest Degenhardt, COL, MSN, NP, USA; Evelyn Patterson, RN, MSN, MBA; Marjory Waterman, RN, MN

Healthcare Quality Informatics, Inc.: Rosalie Fishman, RN, MSN, CPHQ; Joanne Marko, MS, SLP

Research: Sue Radcliff

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: U.S. Department of Veteran Affairs, Veterans Health Administration, Veterans Health Administration. DoD/VA clinical practice guideline for the management of uncomplicated pregnancy. Washington (DC): Department of Veteran Affairs; 2002 Oct. Various p. [533 references]

Guideline Availability

Electronic copies: Available from the Department of Veterans Affairs Web site External Web Site Policy.

Print copies: Available from the Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

Availability of Companion Documents

The following is available:

  • VA/DoD clinical practice guideline for the management of pregnancy. Guideline summary. Washington (DC): Department of Veterans Affairs (U.S.); 2009. 61 p. Electronic copies: Available from the Department of Veterans Affairs Web site External Web Site Policy.

Print copies: Department of Veterans Affairs, Veterans Health Administration, Office of Quality and Performance (10Q) 810 Vermont Ave. NW, Washington, DC 20420.

In addition, the following is available in the appendices of the original guideline document:

  • Screening Items for Self-Administered Questionnaire - First Visit
Patient Resources

None available

NGC Status

This summary was completed by ECRI on May 5, 2004. This summary was updated by ECRI Institute on October 3, 2007 following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This summary was updated by ECRI Institute on May 5, 2009, following the U.S. Food and Drug Administration (FDA) advisory on Rocephin (ceftriaxone sodium). This NGC summary was updated by ECRI Institute on August 3, 2010.

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