Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + ANEMIA Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendation ++ USPSTF 2015, AAFP 2014, ACOG 2008, CDC 1998. ++ –Screen all women with hemoglobin or hematocrit at first prenatal visit. ++ Sources ++ –USPSTF. https://www.uspreventiveservicestaskforce.org/ –Ann Intern Med. 2015;163:529-536. –ACOG. Obstet Gynecol. 2008;112(1):201. –CDC. MMWR Morb Mortal Wkly Rep. 1998; 47(RR-3):1. –Am Fam Physician. 2014;89(3):199-208. +++ Comments ++ Insufficient evidence to recommend for or against routine screening for iron deficiency anemia (IDA) in pregnant women to prevent adverse maternal or birth outcomes. Insufficient evidence to recommend for or against use of iron supplements for non-anemic pregnant women. (USPSTF, 2015) When acute stress or inflammatory disorders are not present, a serum ferritin level is the most accurate test for evaluating IDA. Among women of childbearing age, a cutoff of 30 ng/mL has sensitivity of 92%, specificity of 98%. (Blood. 1997;89:1052-1057) Oral iron is first line therapy for IDA in pregnancy. IV iron is preferred choice (after 13th week) for those who have oral iron intolerance. Cobalamin and folate deficiency should be excluded. (Blood. 2017;129:940-949) Decision to transfuse should be based on the hemoglobin, clinical context, and patient preferences. May be appropriate in severe anemia (<7 mg/dL according to WHO) in whom a 2-wk delay in Hb rise with oral iron may result in significant morbidity. + BACTERIAL VAGINOSIS Download Section PDF Listen +++ +++ Population ++ –Pregnant women at high riska for preterm delivery. +++ Recommendation ++ USPSTF 2008 ++ –Insufficient evidence to recommend for or against routine screening. +++ Population ++ –Low-risk pregnant women. +++ Recommendation ++ USPSTF 2008 ++ –Do not screen routinely. ++ Source ++ –USPSTF. Bacterial Vaginosis in Pregnancy to Prevent Preterm Delivery: Screening. 2008. + ++ aRisk factors: African-American race or ethnicity, body mass index less than 20 kg/m2, previous preterm delivery, vaginal bleeding, shortened cervix <2.5 cm, pelvic infection, bacterial vaginosis. + BACTERIURIA, ASYMPTOMATIC Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendation ++ USPSTF 2008, AAFP 2006 ++ –Screen for bacteriuria at first prenatal visit or at 12–16 wk gestation. –Treat pregnant women who have asymptomatic bacteriuria with antimicrobial therapy for 3–7 d. ++ Sources ++ –USPSTF. Asymptomatic Bacteriuria in Adults: Screening. 2008. –Am Fam Physician. 2006;74(6):985-990. + CHLAMYDIA AND GONORRHEA Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ CDC 2015, AAFP 2012, AAP/ACOG 2012 ++ –Screen all women at first prenatal visit. –If infection detected, obtain test of cure 3–4 wk after treatment. –If chlamydia detected during 1st trimester, repeat within 3–6 mo or re-test in 3rd trimester. ++ Sources ++ –CDC. Sexually Transmitted Diseases Treatment Guidelines. 2015. –Am Fam Physician. 2012;86(12):1127-1132. –AAP & ACOG. Guidelines for Perinatal Care. 7th ed. 2012. + DIABETES MELLITUS, GESTATIONAL (GDM) Download Section PDF Listen +++ +++ Population ++ –Pregnant women after 24 wk of gestation. +++ Recommendation ++ USPSTF 2014 ++ –Recommends screening for gestational diabetes mellitus in asymptomatic pregnant women. ++ Source ++ –USPSTF. Gestational Diabetes Mellitus: Screening. 2014. +++ Recommendations ++ ACOG 2018 ++ –Perform 1-h glucose screening test with 50-g anhydrous glucose load between 24 and 28 gestational weeks. Use a cutoff value of either 135 or 140 mg/dL. –Perform early screening for undiagnosed diabetes, preferably at the initiation of prenatal care, in overweight and obese women with additional diabetic risk factors, including those with a prior history of GDM. –Perform a 3-h glucose tolerance test if the 1-h glucose screening test is abnormal. Use either the Carpenter and Coustan criteria or the National Diabetes Data Group criteria. –Target glucose values in women with GDM are <95 mg/dL fasting, <140 mg/dL 1-h postprandial, or <120 mg/dL 2-h postprandial. –Screen women with GDM 6–12 wk postpartum for overt diabetes. ++ Source ++ –ACOG. Gestational Diabetes Mellitus. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2018 (ACOG practice bulletin; no. 190). +++ Comments ++ Insufficient evidence to support screening for gestational diabetes prior to 24 gestational weeks. Insufficient evidence to define the optimal frequency of blood glucose testing in women with GDM. Based on the data available, consider glucose monitoring 4 times a day, once fasting and again after each meal. + DIABETES MELLITUS (DM), TYPE 2 Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ ADA 2018, ACOG 2018 ++ –Screen for undiagnosed DM type 2 at first prenatal visit if risk factors for DM are present.a –For all other women, screen at 24–28 wk with 75-g 2-h oral glucose tolerance test (OGTT) in the morning after an overnight fast of at least 8 h. 50-g 1-h OGTT followed by 100-g 3-h if 1 h is elevated (threshold: 130–140 mg/dL). ++ Sources ++ –Diabetes Care 2018;41(suppl 1). –Obstet Gynecol. 2018;131(2):e49. +++ Comments ++ Preexisting diabetes if: Fasting glucose ≥126 mg/dL. 2-h glucose ≥200 mg/dL after 75-g glucose load. Random glucose ≥200 mg/dL with classic hyperglycemic symptoms. Hemoglobin A1c ≥6.5%. Criteria for GDM by 75-g 2-h OGTT if any of the following are abnormal: Fasting ≥92 mg/dL (5.1 mmol/L). 1 h ≥180 mg/dL (10.0 mmol/L). 2 h ≥153 mg/dL (8.5 mmol/L). Criteria for GDM by 100-g 3-h OGTT Carpenter–Coustan: Fasting ≥95 mg/dL (5.3 mmol/L). 1 h ≥180 mg/dL (10.0 mmol/L). 2 h ≥155 mg/dL (8.6 mmol/L). 3 h ≥140 mg/dL (7.8 mmol/L). National Diabetes Data Group Fasting ≥105 mg/dL (5.8 mmol/L). 1 h ≥190 mg/dL (10.6 mmol/L). 2 h ≥165 mg/dL (9.2 mmol/L). 3 h ≥145 mg/dL (8.0 mmol/L). A1c screening has lower sensitivity than OGTT and is not recommended as a sole screening tool. + FETAL ANEUPLOIDY Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ ACOG 2016 ++ –Offer screening to all women, ideally during first prenatal visit. The decision should be reached through informed patient choice, including discussion of sensitivity, positive screening and false-positive rates, and risks/benefits of diagnostic testing (amniocentesis and chorionic villous sampling). –No one screening test is superior. ++ Source ++ –Obstet Gynecol. 2016:127(5);e123-e137. +++ Comment ++ Risk of chromosomal anomaly by maternal age at term: 20-y-old: 1 in 525. 30-y-old: 1 in 384. 35-y-old: 1 in 178. 40-y-old: 1 in 62. 45-y-old: 1 in 18. + GROUP B STREPTOCOCCAL (GBS) DISEASE Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ CDC 2010, AAFP 2015 ++ –Universal screening of all women at 35–37 gestational weeks for GBS colonization with a vaginal–rectal swab. –If screening is performed at 35 wk gestation, rescreening is not required for the remainder of the pregnancy. –If screening is performed prior to 35 wk gestation, repeat screening 5 wk later or after 35 wk gestation ++ Sources ++ –AAFP. Clinical Recommendation: Group B Strep. 2015. –CDC. Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC. 2010. –https://www.cdc.gov/groupbstrep/clinicians/qas-obstetric.html +++ Comments ++ Women who are colonized with GBS should receive intrapartum antibiotic prophylaxis to prevent neonatal GBS sepsis. Even women planning a C-section benefit from GBS screening, in case of premature rupture of membranes. + HEPATITIS B VIRUS INFECTION Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendation ++ USPSTF 2009, CDC 2015, ACOG 2015, AAP 2012, AAFP 2009 ++ –Screen all women with HBsAg at their first prenatal visit. ++ Sources ++ –Ann Intern Med. 2009;150(12):874-876. –ACOG/CDC. Screening and Referral Algorithm for Hepatitis B Virus (HBV) Infection among Pregnant Women. 2015. –AAP/ACOG. Guidelines for Perinatal Care. 7th ed. 2012. –AAFP. Clinical Recommendation: Hepatitis. 2009. –CDC. Sexually Transmitted Diseases Treatment Guidelines. 2015. +++ Comments ++ Breast-feeding is not contraindicated in women with chronic HBV infection if the infant has received hepatitis B immunoglobulin (HBIG)-passive prophylaxis and vaccine-active prophylaxis. All pregnant women who are HBsAg-positive should be reported to the local Public Health Department to ensure proper follow-up. Immunoassays for HBsAg have sensitivity and specificity >98%. (MMWR. 1993;42:707) + ++ aImmigrants from Asia, Africa, South Pacific, Middle East (except Israel), Eastern Europe (except Hungary), the Caribbean, Malta, Spain, Guatemala, and Honduras. + HEPATITIS C VIRUS (HCV) INFECTION, CHRONIC Download Section PDF Listen +++ +++ Population ++ –Pregnant women at increased risk.a +++ Recommendation ++ ACOG 2012, CDC 2015 ++ –Perform routine counseling and testing at the first prenatal visit. ++ Sources ++ –American College of Obstetricians and Gynecologists (ACOG). Viral Hepatitis in Pregnancy. Washington (DC): ACOG; 2007. (ACOG practice bulletin; no. 86) –CDC. Sexually Transmitted Diseases Treatment Guidelines. 2015. +++ Comments ++ Route of delivery has not been shown to influence rate of vertical transmission of HCV infection. Reserve cesarean sections for obstetric indications only. Breast-feeding is not contraindicated in women with chronic HCV infection. HCV RNA testing should be performed for: Positive HCV antibody test result in a patient. When antiviral treatment is being considered. Unexplained liver disease in an immunocompromised patient with a negative HCV antibody test result. Suspicion of acute HCV infection. HCV genotype should be determined in all HCV-infected persons prior to interferon treatment. Seroconversion may take up to 3 mo. Of persons with acute hepatitis C, 15%–25% resolve their infection; of the remaining, 10%–20% develop cirrhosis within 20–30 y after infection, and 1%–5% develop hepatocellular carcinoma. Patients testing positive for HCV antibody should receive a nucleic acid test to confirm active infection. A quantitative HCV RNA test and genotype test can provide useful prognostic information prior to initiating antiviral therapy. (JAMA. 2007;297:724) + ++ aHCV risk factors: HIV infection; sexual partners of HCV-infected persons; persons seeking evaluation or care for STDs, including HIV; history of injection-drug use; persons who have ever been on hemodialysis; intranasal drug use; history of blood or blood component transfusion or organ transplant prior to 1992; hemophilia; multiple tattoos; children born to HCV-infected mothers; and health care providers who have sustained a needlestick injury. + HERPES SIMPLEX VIRUS (HSV), GENITAL Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendation ++ CDC 2015, USPSTF 2016 ++ –Do not screen routinely for HSV with serologies. ++ Sources ++ –JAMA. 2016;316(23):2525-2530. –CDC. Sexually Transmitted Diseases Treatment Guidelines. 2015. +++ Comments ++ In women with a history of genital herpes, routine serial cultures for HSV are not indicated in the absence of active lesions. Women who develop primary HSV infection during pregnancy have the highest risk for transmitting HSV infection to their infants. + HUMAN IMMUNODEFICIENCY VIRUS (HIV) Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ AAFP 2010, USPSTF 2013, ACOG 2015, CDC 2015 ++ –Screen all pregnant women for HIV as early as possible during each pregnancy, using an opt-out approach. –Repeat HIV testing in 3rd trimester for women in areas with high HIV incidence or prevalence. –Offer rapid HIV screening to women in labor who were not tested earlier in pregnancy or whose HIV is undocumented. If rapid HIV test is reactive, initiate antiretroviral prophylaxis immediately while waiting for supplemental test results. ++ Sources ++ –AAFP. Clinical Recommendation: HIV Infection, Adolescents and Adults. 2013. –USPSTF. HIV Infection: Screening. 2013. –CDC. Sexually Transmitted Diseases Treatment Guidelines. 2015. –ACOG. Committee Opinion: Committee on Obstetric Practice and HIV Expert Work Group. Obstet Gynecol. 2015;125:1544-1547. +++ Comment ++ Rapid HIV antibody testing during labor identified 34 HIV-positive women among 4849 women with no prior HIV testing documented (prevalence: 7 in 1000). Eighty-four percent of women consented to testing. Sensitivity was 100%, specificity was 99.9%, positive predictive value was 90%. (JAMA. 2004;292:219). + PREECLAMPSIA Download Section PDF Listen +++ +++ Population ++ Pregnant women. +++ Recommendation ++ USPSTF 2017 ++ –Screen with blood pressure measurements throughout pregnancy. ++ Source ++ –JAMA. 2017;317(16):1661-1667. +++ Comments ++ Screening for protein with urine dipstick has low accuracy. Diagnose preeclampsia if blood pressure is ≥140/90 ×2, 4 h apart, after 20 wk gestation AND there is proteinuria (≥300 mg/dL in 24 h or protein:creatinine ratio ≥0.3, or protein dipstick ≥1+), thrombocytopenia, renal insufficiency, impaired liver function, pulmonary edema, or cerebral/visual symptoms. + LEAD POISONING Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ AAFP 2006, USPSTF 2006, CDC 2000, AAP 2000, ACOG 2012 ++ –Insufficient evidence to recommend for or against routine screening for women at increased risk.a –CDC and ACOG do not recommend blood lead testing of all pregnant women in the United States. –For pregnant women with blood levels of 5 μg/dL or higher, sources of lead exposure should be identified and women should receive counseling. Maternal or umbilical cord blood lead levels should be measured at delivery. ++ Sources ++ –USPSTF. Lead Levels in Childhood and Pregnancy: Screening. 2006. –Pediatrics. 1998;101(6):1702. –Advisory Committee on Childhood Lead Poisoning Prevention. Recommendations for blood lead screening of young children enrolled in Medicaid: Targeting a group at high risk. CDC MMWR. 2000;49(RR14);1-13. –AAFP. Clinical Recommendations: Lead Poisoning. 2006. –Obstet Gynecol. 2012;120:416-420. –AAFP. Clinical Recommendations: Lead Poisoning. 2006. + ++ aImportant risk factors for lead exposure in pregnant women include recent immigration, pica practices, occupational exposure, nutritional status, culturally specific practices such as the use of traditional remedies or imported cosmetics, and the use of traditional lead-glazed pottery for cooking and storing food. + RH (D) INCOMPATIBILITY Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ AAFP 2010, USPSTF 2007, ACOG 2017 ++ –Order ABO type and Rh (D) antibody testing for all pregnant women at their first prenatal visit. –Repeat Rh (D) antibody testing for all unsensitized Rh (D)-negative women at 24–28 wk gestation. ++ Sources ++ –http://www.guideline.gov/content.aspx?id=38619 –Obstet Gynecol. 2017;13:e57-70. –http://www.uspreventiveservicestaskforce.org/3rduspstf/rh/rhrs.htm +++ Comment ++ Rh (D) antibody testing at 24–28 wk can be skipped if the biologic father is known to be Rh (D)-negative. + SYPHILIS Download Section PDF Listen +++ +++ Population ++ –Pregnant women. +++ Recommendations ++ CDC 2015, AAFP 2009, USPSTF 2009, WHO 2017 ++ –Screen all pregnant women at the first prenatal visit. –Screen again at 28 gestational weeks if high risk or previously untested. ++ Sources ++ –CDC. Sexually Transmitted Diseases Treatment Guidelines. 2015. –USPSTF. Syphilis Infection in Pregnancy: Screening. 2009. –WHO. Syphilis Screening and Treatment for Pregnant Woman. 2017. –https://www.aafp.org/patient-care/clinical-recommendations/all/syphilis.html. +++ Comments ++ A nontreponemal test (Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagent [RPR] test) should be used for initial screening. All reactive nontreponemal tests should be confirmed with a fluorescent treponemal antibody absorption (FTA-ABS) test. If high risk, consider testing a third time at the time of delivery. Syphilis is a reportable disease in every state. + THYROID DISEASE Download Section PDF Listen +++ +++ Population ++ –Women who are pregnant or immediately postpartum. +++ Recommendations ++ ATA 2017, AAFP 2014 ++ –Insufficient evidence to recommend for or against routine screening of all women. –Targeted screening of women at high risk. –Obtain TSH levels at confirmation of pregnancy if: A history or current symptoms of thyroid dysfunction. Known thyroid antibody positivity or presence of a goiter. History of head or neck radiation or prior thyroid surgery. Age >30 y. Autoimmune disorders. History of pregnancy loss, preterm delivery, or infertility. Multiple prior pregnancies. Family history of thyroid disease. BMI ≥40 kg/m2. Use of amiodarone or lithium, or recent administration of iodinated radiologic contrast. Residing in an area of known moderate-to-severe iodine insufficiency. ++ Sources ++ –Thyroid. 2017;27(3):315. –Am Fam Physician. 2014;89(4):273-278. + TOBACCO USE Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendation ++ AAFP 2015, USPSTF 2015, ICSI 2014 ++ –Screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. +++ Population ++ –Pregnant women. +++ Recommendation ++ AAFP 2015, USPSTF 2015, ICSI 2014 ++ –Screen all pregnant women for tobacco use and provide pregnancy-directed counseling and literature for those who smoke. ++ Sources ++ –AAFP. Clinical Preventive Service Recommendation: Tobacco Use. 2015. –USPSTF. Tobacco Smoking Cessation in Adults, Including Pregnant Women: Behavioral and Pharmacotherapy Interventions. 2015. –ICSI. Preventive Services for Adults. 20th ed. 2014. +++ Comment ++ The “5-A” framework is helpful for smoking cessation counseling: Ask about tobacco use. Advise to quit through clear, individualized messages. Assess willingness to quit. Assist in quitting. Arrange follow-up and support sessions.