Download Exercise in Pregnancy - Association of Professors of Gynecology

Routine Antepartum Care
Rita W. Driggers, MD
Associate Professor of
Gynecology and Obstetrics
Johns Hopkins University
School of Medicine
Objectives
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At the conclusion of this session, attendees will
summarize:
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Timing of appointments and tests/topics to be addressed at
each prenatal visit for the uncomplicated pregnancy
Current recommendations involving the following in the
setting of pregnancy:
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Diet and weight gain
Exercise
Travel and travel prophylaxis
Immunizations
Tobacco, alcohol, and caffeine use
Psychiatric medications
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29yo G0 presents for routine health maintenance
and informs you she would like to conceive in the
next year. H&P are unremarkable. She states she
eats a well balanced diet but enjoys and has become
accustomed to having 3 lattes each morning and 2
glasses of wine with dinner each night.
At this time you would advise the
patient:
1)
2)
3)
She should quit drinking lattes now because
increased caffeine intake is associated with
recurrent pregnancy loss
She can continue to have her lattes now but should
stop or cut down once pregnant because increased
caffeine intake is associated with IUGR
She can continue to drink lattes but should limit
caffeine intake to 200mg/d preconceptionally and
during the 1st trimester
At this time you would advise the
patient:
1)
2)
3)
1oz of alcohol (1 beer, 1 glass of wine, 1 single-shot
mixed drink) per day in the 2nd or 3rd trimester, but
not in the 1st trimester, has been shown to be safe
in pregnancy
No level of alcohol use, even the most minimal
drinking, has been determined to be absolutely safe
in pregnancy
Alcohol-related adverse pregnancy outcomes
include spontaneous abortion, nervous system
impairment, birth defects, and fetal alcohol
syndrome
Caffeine and Pregnancy
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Conflicting reports whether increased caffeine intake is
associated with spontaneous miscarriages
Not believed to be a cause of recurrent pregnancy loss
Recent study suggests intake >200mg/day (approximately
10oz coffee or 25oz tea) doubles the risk of 1st trimester
miscarriage (24.5%)
In non-smokers, caffeine use has not been shown to be
associated with intrauterine growth restriction in amounts up
to 4000mg per week
Caffeine ingestion temporarily increase blood pressure
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Should not be ingested 30 minutes prior to vitals
Used judiciously if pregnancy complicated by hypertension
Alcohol Use and Pregnancy
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Fetal alcohol syndrome (FAS) - leading cause of
mental retardation in United States
12% of pregnant women admit to drinking some
alcohol during the previous month
No level of alcohol use, even the most minimal
drinking, has been determined to be absolutely
safe during pregnancy
Abstinence is the only known way to avoid all
alcohol-related adverse pregnancy outcomes
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Spontaneous abortion
Nervous system impairment
Birth defects
FAS
Routine Prenatal Care
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Goal of antepartum care is to reduce risk of adverse
health effects for the woman, fetus, and neonate
For low risk patients, the VA/DoD Clinical Practice
Guideline for Management of Uncomplicated
Pregnancy may be followed
Patient evaluated at 6-8 weeks
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Initial labs drawn
Risk factors that may impact pregnancy identified
Appropriate referrals made
Patient assigned to routine or high risk obstetric care
Routine Prenatal Care
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If uncomplicated, subsequent appointments at
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10-12 weeks
16-20 weeks
24 weeks
28 weeks
32 weeks
36 weeks
weekly beginning at 38 weeks
Instruct patient where to be seen for complications
that cannot wait until next scheduled appointment to
be addressed
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A 33yo G3P2002 presents for her initial OB
evaluation. She states she was never able to
lose all the weight she gained in her prior
pregnancy (60lbs) and wants your
recommendation for weight gain during this
pregnancy.
You calculate her BMI to be 28kg/m2.
Which of the following is/are true?
1)
2)
3)
4)
The patient is of normal weight and should
gain 25-35lbs
The patient is overweight and should gain
no more than 15-25lbs
The patient is obese and should limit her
weight gain to no more than 15lbs
The patient is obese and should be followed
by your partner
Obese women are at increased risk of
which of the following pregnancy
complications:
1)
2)
3)
4)
5)
Cesarean delivery
Congenital anomalies
Gestational hypertension
Preeclampsia
Gestational diabetes
Obesity and Pregnancy
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Institute of Medicine recommended weight gain during
pregnancy
– BMI <18.5 kg/m2 (underweight): 28 to 40 lbs
– BMI 18.5 to 24.9 kg/m2 (normal weight): 25 to 35 lbs
– BMI 25.0 to 29.9 kg/m2 (overweight): 15 to 25 lbs
– BMI ≥30.0 kg/m2 (obese):11 to 20 lbs (5 to 9.0 kg)
Obese women are at increased risk for
– Gestational hypertension
– Preeclampsia
– Gestational diabetes
– Cesarean delivery
Obesity and Pregnancy
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Ideally, encourage obese patients to begin a weight loss
program prior to attempting to conceive
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Nutrition counseling should be offered to all obese women
Encourage to follow an exercise program
Consider early gestational diabetes screening
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Diet, exercise, and behavior modification
Repeat screening later in pregnancy if early results negative
If delivered by cesarean section
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Early ambulation
Hydration
Use of graduated compression stockings
After counseling your patient about risks of
obesity in pregnancy, she decide she wants to
start exercising. You advise her:
1)
2)
3)
4)
In the absence of either medical or obstetric
complications, 30 minutes or more of
moderate exercise per day on most, if not
all, days of the week is recommended
Participation in wide range of exercise
programs and recreational activities during
pregnancy is safe
Exercise at altitudes up to 6,000 feet safe
Scuba diving should be avoided
Exercise in Pregnancy
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Each activity evaluated for potential risks (eg, falling
or abdominal trauma)
Absolute contraindications to aerobic exercise:
– Hemodynamically significant heart disease
– Restrictive lung disease
– Incompetent cervix
– Preterm labor
– Ruptured membranes
– Preeclampsia or pregnancy induced hypertension
– Persistent 2nd or 3rd trimester bleeding
– Placenta previa
– Multiple gestation
Exercise in Pregnancy
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Relative contraindications to aerobic exercise:
– Severe anemia
– Unevaluated arrhythmia
– Chronic bronchitis
– Extreme morbid obesity
– Extremely sedentary lifestyle
– Extreme underweight (BMI <12)
– Poorly controlled hypertension, hyperthyroidism,
seizures
– Brittle Type 1 diabetes
– Orthopedic limitations
– Heavy smoking
Exercise in Pregnancy
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Warning signs to terminate exercise:
– Vaginal bleeding
– Dyspnea prior to exertion
– Dizziness, headache, chest pain
– Muscle weakness, calf pain or swelling
– Preterm labor
– Decreased fetal movement
– Amniotic fluid leakage
Exercise in Pregnancy
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Following delivery
– Pre-pregnancy exercise routines may be resumed
gradually
– Some may resume exercise routine within days,
others may take 4-6 weeks
– Return to physical activity after pregnancy
associated with decreased incidence of
postpartum depression
Initial OB Visit (10-12 weeks)
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Review and record all initial labs
– Blood type, Rh and antibody screen
– CBC
– Hemoglobin electrophoresis if indicated
– UA, urine C&S
– RPR, Rubella titer, HIV, HBsAg
Address significant abnormalities and list on
problem list
Initial OB Visit (10-12 weeks)
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Review of systems and medical history with emphasis on items
that may impact OB management
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Family medical history with emphasis on
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Teratogen exposure, smoking, ETOH, drug and medication use
History of genital herpes, STD, and patient occupation/exposures
Blood transfusions/blood products
Diabetes
Seizure disorders
SLE
Diabetes
Chronic hypertension
Collagen vascular diseases
Genetically inherited diseases/teratology
Genetic counseling if indicated
Initial OB Visit (10-12 weeks)
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Record any notable symptoms since LMP
Perform and record a complete physical exam
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Cervical swab for chlamydia and gonococcus testing and
Pap
Breast examination
Evaluate uterine size
Perform clinical pelvimetry
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Diagonal conjugate estimated by inserting 2nd and 3rd fingers
into vagina measuring the distance from sacral promontory to
the lower margin of symphysis pubis
Adequate diagonal conjugate is >11.5cm
Document assessment, follow-up plan, and any
indicated special procedures
Initial OB Visit (10-12 weeks)
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Patient problem list utilized for
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Calling attention to problems
Addressing special management plans
List current medications on a medication list
Document allergies to medications and type of
reaction
If previous Cesarean delivery or uterine surgery
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Get details of indication and type of uterine scar
Review operative report and place a copy in chart
If candidate for a trial of labor (TOL), counsel as to risks and
benefits
Initial OB Visit (10-12 weeks)
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Cystic fibrosis (CF) and maternal serum screening
counseling
Indications for nutrition counseling:
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Underweight mothers
Morbid obesity
Poor weight gain
Eating disorders
History of nutritional deficiencies or anemia
Vegetarians
Teen mothers
Weight reduction surgery (gastric bypass, etc.)
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A 33yo G1P0 presents for her 10 week
antepartum appointment. She reports her
sister delivered at 28 weeks and wants to
know what can be done to screen for preterm
birth during her pregnancy
You would recommend to this
patient:
1)
2)
3)
4)
Home uterine activity monitoring later in
pregnancy
Frequent evaluations for bacterial vaginosis
Serial fetal fibronectin tests
Cervical length measurement
Screening for Preterm Birth
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Infants born prematurely have increased morbidity
and mortality
One of the strongest clinical risk factors for preterm
birth is a prior preterm birth
Other factors associated with increased risk of PTB
– Vaginal bleeding
– Urinary tract infections
– Genital tract infections
– Periodontal disease
Treatment not shown to decrease risk
Screening for Preterm
Birth
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Fetal fibronectin
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Extracellular matrix glycoprotein
Marker for disruption of chorioamnion and
underlying decidua
Negative test useful in ruling out PTB
 Negative predictive value for delivery <37
weeks: 69-92%
 Negative predictive value for not
delivering within next 14 days: >95%
Screening for Preterm Birth
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ACOG Practice Bulletin #130, October 2012
– Tests such as fetal fibronectin screening, bacterial
vaginosis testing, and home uterine activity
monitoring are not recommended as screening
strategies
– Short cervical length measured by transvaginal
ultrasonography has been associated with
increased risk of preterm birth
– Cervical length screening strategy may be
considered
16-20 Week Visit
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Offer 2nd trimester maternal serum screening
At this and each subsequent visit
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Blood pressure
Weight gain
Fundal height
Fetal heart tones
16-20 Week Visit
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The following warrant further evaluation:
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Blood pressure > 140 systolic
Blood pressure > 90 diastolic
Urine protein > 1+
Vaginal bleeding
Loss of fluid per vagina
Lack of fetal movement if over 20 weeks gestation
16-20 Week Visit
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Sonographic evaluation of fetal anatomy at 16-20 wks
Document
– Presence or absence of fetal movement
– Time of next follow-up visit
– Discuss management plans
Patient education topics should include
– Breastfeeding
– Exercise
– Vaccinations
– Family planning
– Domestic abuse
27yo G2P1 at 16+0 weeks wants to get up to date on her
immunizations. She has no chronic medical problems.
Which are NOT contraindicated in pregnancy:
1)
2)
3)
4)
5)
6)
Measles
Mumps
Polio
Anthrax
Influenza nasal vaccine
Influenza IM vaccine
Immunizations/Travel Prophylaxis
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Current information on safety of vaccines
during pregnancy subject to change
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Centers for Disease Control and Prevention web
site at www.cdc.gov/vaccines/
Currently, only live attenuated virus
vaccines are contraindicated
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Measles, mumps, rubella
Poliomyelitis
Yellow fever
Varicella
Immunizations/Travel Prophylaxis
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Influenza
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Administer to women pregnant during the influenza season
(October through May)
Intranasal influenza vaccine spray contains a live, attenuated
virus
Intramuscular inactivated vaccine should be used
Vaccination of women susceptible to rubella and
varicella should be encouraged postpartum
Typhoid and Hepatitis A vaccinations recommended
for pregnant patients traveling to endemic areas
Anthrax vaccination recommended to pregnant
women who work directly with B anthracis or military
personnel deployed to high-risk exposure areas
24 Week Visit
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Signs/symptoms of preterm labor
Fetal kick counts
Symptoms of preeclampsia
Other patient education topics
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Breastfeeding
Exercise
Vaccinations
Family planning
Domestic abuse
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At her 24 week appointment your patient
confides that she was treated with sertraline
for postpartum depression following her last
delivery but discontinued it prior to
attempting to conceive due to concerns for
teratogenicity.
Recently she has become more depressed but is
concerned about the effects of sertraline on the
fetus. You inform her that
1)
2)
3)
4)
It would be preferable to treat her with 2
antidepressants at a lower dose
The major risk of teratogenesis is during the 3rd –
8th weeks of gestation
SSRIs have been associated with increased risk of
cardiac defects in exposed fetuses but paroxetine
is preferred over sertraline
If she wants to be depressed she should look at
your clinic schedule and you don’t have time to deal
with this
Psychiatric Medications in Pregnancy
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Inadequately treated maternal psychiatric illness
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Poor compliance with prenatal care
Poor nutrition
Self-medication
Increased alcohol or tobacco abuse
Inadequate maternal-infant bonding
Disruptions to the home environment
Discontinuing psychiatric medications exchanges
fetal risks of medication exposure for risks of
untreated maternal psychiatric illness
A single medication at a higher dose is preferred
over multiple medications
Psychiatric Medications in Pregnancy
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Teratogenesis
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Patient with mild illness
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Major risk during embryogenesis (3rd – 8th weeks)
If medication is known to be teratogenic, consider tapering
before conception
If necessary, reinstitute after organogenesis
Patient with severe illness
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Continue medication throughout gestation
Counsel the patient about the risks
Order studies (targeted anatomic survey, fetal
echocardiogram) to evaluate fetus
Psychiatric Medications in Pregnancy
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Treatment with selective serotonin reuptake
inhibitors (SSRIs) or selective
norepinephrine reuptake inhibitors
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Should be individualized
Paroxetine use increases risk of cardiac defects
in exposed fetuses and should be avoided
Lithium, valproate, and carbamazepine are
associated with an increased risk of fetal
anomalies and should be avoided,
especially during organogenesis
28 Week Visit
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28 week labs
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CBC
Blood type, Rh and antibody screen
Glucola screen
Rhogam
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Rh negative, non-immunized patients
Following any procedure/complication which
places the patient at risk for fetal-maternal bleed
28 Week Visit
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Diabetes screening
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Oral 50 gram glucola challenge followed by serum glucose
level in one hour
Should be performed on any new OB patients with
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History of macrosomia (greater than 4500 grams)
Unexplained stillbirth
Prior child with a congenital anomaly
Family history of diabetes
Maternal obesity
Persistent maternal glycosuria
Alternatively, screen all patients at 24-28 weeks
Abnormal result followed up with 3 hour OGTT
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You call your patient to inform her that she
has 2 abnormal values on her 3hr OGTT and
that you will be referring her for dietary
counseling and teaching on home glucose
monitoring. She gets upset and states she
believes she is diabetic because she quit
smoking for the pregnancy but gained 50 lbs
as a result. She states that the only way she
can be compliant with the ADA diet is to
resume smoking.
You inform her that she should not smoke because
this will increase her risk of adverse pregnancy
outcomes to include:
1)
2)
3)
4)
5)
Abruption
Fetal growth restriction
PROM
Previa
Ectopic pregnancy
You also inform her that children born to smokers
are at increased risk for:
1.
2.
3.
4.
SIDS
Childhood obesity
Infantile colic
Asthma
Tobacco Abuse in Pregnancy
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One of most important modifiable causes of poor
pregnancy outcomes
Maternal smoking results in:
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Fetal hypoxia from increased carboxyhemoglobin
Reduced blood flow to the uterus, placenta, and fetus
Direct effects of nicotine and other compounds in tobacco
on placenta and fetus
Nicotine gum, lozenges, patches, inhalers, and
antidepressants that reduce withdrawal symptoms
should be considered during pregnancy and
lactation when non-pharmacologic treatments failed
Tobacco Abuse in Pregnancy
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The 5A’s of intervention (adapted from the U.S.
Public Health Service clinical practice guideline):
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Ask about smoking status
Advise by providing clear, strong advice to quit with
personalized messages about the benefits of quitting and
the impact of continued smoking on patient, her fetus, and
newborn
Assess willingness of the patient to quit
Assist by suggesting and encouraging use of problemsolving methods and skills for smoking cessation
Arrange follow up visits to track progress
32 Week Visit
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Review 28 week labs
Address any patient concerns/complaints
Re-address
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preterm labor
preeclampsia
fetal kick count precautions
At her 32 week visit, your patient tells you that she
plans to take an international flight. Her pregnancy
has been uncomplicated. You inform her:
1)
2)
3)
4)
She is beyond the EGA cut off for most international
airlines
The reduced humidity in the airplane cabin causes
hemoconcentration which increases risk for venous
thrombosis
Periodic movement, support stockings, and
hydrating may decrease risk of thrombosis
She can travel but should use supplemental oxygen
during the flight
Air Travel in Pregnancy
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In absence of obstetric/medical complications can fly up to 36
weeks
Reduced cabin humidity causes hemoconcentration
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Venous thrombosis
Preterm labor
Patients with medical problems exacerbated by hypoxic
environment - prescribe supplemental oxygen during air travel
Patients at significant risk for preterm labor or with placental
abnormalities should avoid air travel
Most U.S airlines allow up to 36 weeks gestation
For international airlines, the cutoff is 35 weeks
For specific airline requirements, the patient should check
with the specific carrier
36 Week Visit
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Obtain GBS culture
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Address any patient concerns/complaints
Re-address
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Request sensitivities if penicillin allergic
Preeclampsia
Fetal kick count precautions
Instruct patient on signs of labor
38-41 Week Visits
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Cervical check
Consider membrane sweeping
Address any patient concerns/complaints
Re-address
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Preeclampsia
Fetal kick count precautions
Signs of labor
May schedule induction of labor at or after 41 weeks
Begin post-dates antepartum testing if not delivered
by 41 weeks
Summary


Timing of appointments and tests/topics to be
addressed at each prenatal visit for the
uncomplicated pregnancy
Current recommendations involving the following in
the setting of pregnancy:






Diet and weight gain
Exercise
Travel and travel prophylaxis
Immunizations
Tobacco, alcohol, and caffeine use
Psychiatric medications
Questions?