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Clinical Practice Guidelines
High-Risk Obstetrics
All member care and related decisions are the sole responsibility of the provider. This information does not dictate nor control your clinical
decisions regarding the appropriate care of members. Guidelines are subject to state regulations and benefits.

2012 Clinical Practice Guideline
Created: 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012

PEC-ALL-0769-12 1

PREGNANCY-INDUCED HYPERTENSION
DEFINITIONS
Preeclampsia is hypertension with proteinuria and edema occurring after 20 weeks but
going away by 12 weeks postpartum.
Mild preeclampsia: 140-159/90-109mm Hg, proteinuria 300mg-4999mg/24 hours
Severe preeclampsia: 160/110mm Hg, 5000mg 24 hours, oliguria, end organ
symptoms (e.g., headache, visual changes, epigastria pain)

Eclampsia is preeclampsia with seizure.

HELLP Syndrome is preeclampsia with H=Hemolysis (the breakdown of red blood cells),
EL=Elevated Liver enzymes and LP=Low Platelet count.

Gestational hypertension is defined as new onset hypertension without proteinuria
occurring after 20 weeks of gestation.
Chronic hypertension is hypertension present before pregnancy or a blood pressure of
140/90 mmHg or more present before the 20th week of pregnancy or that persists
longer than the postpartum period.

Source: American Congress of Obstetricians and Gynecologists (ACOG), Practice Bulletin
Number 29 (July 2001). Reaffirmed 2010.
EFFECTS OF HYPERTENSION ON PREGNANCY
Premature birth, Intrauterine Growth Restriction (IUGR), fetal demise, placental abruption,
perinatal and neonatal morbidity, and mortality.
INITIAL EVALUATION IN CHRONIC HYPERTENSION
Besides a thorough history documenting the age of onset, duration and severity of
hypertension, women with years of involvement tend to need an ophthalmologic exam (to
rule out retinopathy), echocardiogram, electrocardiogram (to rule out ischemic heart
disease and cardiomegaly), renal ultrasound, 24-hour urine for protein and creatinine


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
clearance, as well as a comprehensive metabolic panel (to rule out renal involvement).
MEDICATION MANAGEMENT
1. Medication and chronic hypertension
Mild-chronic hypertension: As a rule, mild-chronic hypertension does not require
medication although the majority of patients will be medicated if diagnosed prior to
the pregnancy and should probably continue the medication if they are on one of the
two types used in pregnancy. Methyldopa is the gold standard in pregnancy because
of its limited effects on uteroplacental blood flow. Labetalol, a combined alpha-and
beta-blocker can be used as an alternative. Angiotensin-Converting Enzyme (ACE)
inhibitors are contraindicated in pregnancy. Second line medications for hypertensive
control can be oral hydralazine, calcium channel blockers and possibly a catapres
patch.
Severe chronic hypertension requires antihypertensive medication.
Both types of chronic hypertension must be watched for super-imposed
preeclampsia.

2. Medications and acute hypertension
For acute forms of hypertension, especially in labor, hydralazine (5-10mg IV push 20
minutes to a max dose of 40 mg) is the most widely used antihypertensive, while
Labetalol (10-20-mg IV push every 15 minutes to a max single dose of 80 mg and total
dose of 220 mg) is equally as effective. These medications should be used when SBP is
180mm Hg or DBP 110mm Hg. Avoid maternal hypotension.

Although used more often, it is still controversial to use antihypertensive medication in
gestational hypertension.

Consider Maternal Fetal Medicine (MFM) Specialist or Intensivist consult if the patient
continues to be unresponsive to other medications.

3. Seizure Prophylaxis
Magnesium sulfate (MGSO4) is the drug of choice for prevention of seizures. Four
gram bolus over 20 minutes followed by 2 grams per hour. Therapeutic serum levels
4-8mg/dl. Continue postpartum for at least 24 hours.


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13

4. HELLP, severe preeclampsia, severe chronic hypertension and chronic hypertension with
imposed preeclampsia need MgSO4 protocol for prophylaxis.

5. Mild chronic hypertension, gestational hypertension and mild preeclampsia are decided
on a case-by-case basis regarding MGSO4 protocol.
ANTEPARTUM TESTING AND TREATMENT
Although controversial, most would argue that patients diagnosed with chronic
hypertension should receive twice weekly Nonstress Tests (NST) with Amniotic Fluid Index
(AFI) weekly or Biophysical Profile (BPP) weekly along with:
Ultrasound every 4-6 weeks after 28-32 weeks to assess fetal growth
If IGR is suspected, testing should include umbilical artery Doppler flow studies
Weekly NST for gestational hypertensive patients in good control are not indicated
Antenatal corticosteroids
If delivery seems imminent (between 24-34 weeks), steroids should be initiated. Delivery
should not be delayed for steroids if immediate delivery is necessary
Treatment should consist of either two doses of betamethasone or four doses of
dexamethasone as a single course
TIMING FOR DELIVERY
Gestational hypertension: Delivery after 39 weeks based on stability and Bishop score of the
cervix
Delivery should be prolonged until after 39 weeks if the patient is maintaining a
reassuring fetal heart rate.

Chronic hypertension: Pregnant with uncomplicated chronic hypertension of a mild degree
generally can be delivered vaginally at term

Source: ACOG, Practice Bulletin Number 29 (July 2001). Reaffirmed 2010.

Chronic hypertension with super-imposed preeclampsia: Considered based on gestation
and delivery with MgS04 protocol
HELLP syndrome: Delivery with MgS04 protocol


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
Mild preeclampsia
< 39 weeks: Expectant management with clinical judgment regarding maternal and fetal
stability, consider MGSO4 protocol
39 weeks: Delivery and consider MgSO4 protocol

Severe preeclampsia
< 28 weeks: Give steroids, counsel regarding poor outcome and if maternal fetal unit
deteriorating, deliver with MgSO4 protocol and transfer to a tertiary care facility
28-32 weeks: Hospitalize for observation, give steroids and expectant management if
maternal/fetal unit stable. If unstable, deliver with MgSO4 protocol and consider
transfer to a tertiary care facility
32-34 weeks: Consider amniocentesis and if fetal lungs are mature, deliver with MgSO4
protocol. If fetal lungs are immature, give steroids and deliver with MgSO4 protocol
> 34 weeks: Deliver with MgSO4 protocol
Consider MFM consult
FLUID CONTROL
Monitor input and output closely and consider Foley catheter and fluid restriction
If unstable or if in pulmonary edema, consider MFM consult or intensive care specialist if
needed

DIAGNOSIS AND TREATMENT STRATEGIES
LEVEL OF ILLNESS CLINICAL CRITERIA TREATMENT
Preeclampsia Mild Blood Pressure (BP)
140/90 mm Hg
Proteinuria 300
mg/24 hours

37 weeks: Deliver with MgSO
4
protocol
34-37 weeks: Use expectant
management with clinical judgment
regarding maternal and fetal unit
stability
< 34 weeks: Use expectant management
with clinical judgment regarding steroid
therapy
Preeclampsia
Severe
BP of 160/110 mm Hg
Proteinuria > 5Gms/24
hours
> 34 weeks: Deliver with MgSO
4
protocol


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
Oliguria < 500 ml/24
hours
Platelets < 150 K
Increased blood urea
nitrogen, creatinine,
liver enzymes
UUGR/oligohydramnios
End-organ symptoms:
headache, visual
changes, epigastric or
right upper quadrant
pain
32-34 weeks: If fetal lungs are mature,
deliver with MgSO
4
protocol. If fetal
lungs are immature, use steroid
treatment and deliver with MgSO
4
protocol.

28-32 weeks: Hospitalize for
observation. Evaluate the use of
steroids. Expectant management if
maternal/fetal unit stable. If the
maternal/fetal unit is unstable, deliver
with MgSO
4
protocol.

< 28 weeks: Counsel regarding poor
outcome. If the maternal/fetal unit is
deteriorating, deliver with MgSO
4
protocol.
Gestational
Hypertension
BP without proteinuria
HELLP Hemolysis, elevated liver
enzyme, low platelets
Deliver with MgSO
4
protocol
MgSO
4
Protocol Guidelines

Administer IV during labor
Give during initial evaluation for
severe preeclampsia when the plan
is to manage conservatively
Loading dose: 4 Gm (range 2-6 Gm)
over 20 minutes
Maintenance dose: 2-4 Gm/hour
Therapeutic serum levels: 4-8 mg/dl
Postpartum: continue 24 hours or
more until clinical indicators improve


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
BP Control Guidelines Hydralazine 5-10 mg intravenously q
20-30 minutes to a maximum of 40
mg
Labetalol 10-20 mg intravenously
every 15 minutes to a maximum
single dose of 80 mg (total maximum
dose 220 mg)
Fluid Control Guidelines Monitor Input and Output (I&O)
Foley catheter
Pulmonary artery catheter if
hemodynamically unstable or if
pulmonary edema (with MFM
consult)
MFM consult is appropriate for
severe and difficult cases
O
2
saturation

PREGNANCY PRETERM DELIVERY
DEFINITIONS
Preterm delivery is a delivery prior to 37 weeks gestation.

Preterm labor is regular contractions that occur before 37 weeks and are associated with
changes in the cervix.
Tests that can help identify
patients at risk for preterm
delivery
Although many tests have been proposed, only cervical
length by ultrasound and fetal Fibronectin (fFN) have been
shown to have benefits. However, their clinical usefulness
may rest primarily with their ability to identify women who
are least likely to deliver (negative predictive value) as
opposed to predicting those who will deliver before 37
weeks.
A cervical length at 24 weeks of 3.0 or greater has a very
high negative predictive value. A negative fFN between 24-
34 weeks has an even greater negative predictive value.


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
Antenatal testing for
predictability of patients at
risk for preterm delivery:
Tests that can help identify
patients at risk for preterm
delivery

Although many tests have been proposed, only cervical
length by ultrasound and fFN have been shown to have
benefits. However, their clinical usefulness may rest
primarily with their ability to identify women who are least
likely to deliver (negative predictive value), as opposed to
predicting those who will deliver before 37 weeks.
A cervical length at 24 weeks of 3.0 or greater has a very
high negative predictive value. A negative fFN between 24-
34 weeks has an even greater negative predictive value.
Although not as sensitive, combining these two tests can be
part of a preventing preterm delivery algorithm.
Algorithm for preventing
preterm delivery
If the cervical length is greater than 30 mm and/or the fFN is
negative, the patient can be reassured that delivery is not
imminent and can be managed expectantly as an outpatient. If
the cervical length is 20-30 mm, the fFN result can be used to
further triage these patients. Patients with a negative fFN
result can also be managed expectantly and do not require
hospitalization. If the fFN is positive and/or the cervical length
is shorter than 20 mm, these patients warrant close
observation and consideration for additional intervention
including antenatal glucocorticoids or short-term tocolytics.
1. Tocolytics: Do they work?
Tocolytics have only been proven to prolong gestation
for 2-7 days, which can provide time for administration
of steroids and maternal transport to a facility with
Neonatal Intensive Care Unit (NICU).
The Amerigroup MFM advisory panel highly
recommends acute tocolysis for preterm labor.
Consider short-term use of IV MgSO4 for neonatal
neurological protection for patients at risk.
2. Antenatal Corticosteroids: Use them.
The most beneficial intervention for patients in true
preterm labor is the administration of corticosteroids


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
between 24 and 34 weeks gestation. Treatment should
consist of either two doses of betamethasone or four
doses of dexamethasone as a single course.
The use of corticosteroids will decrease the incidence of
intraventricular hemorrhage and necrotizing
enterocolitis, respiratory distress syndrome, as well as
decreased neonatal mortality.
3. Should we use antibiotics?
Antibiotics do not appear to prolong gestation and
should be reserved for Group B Streptococcus (GBS)
prophylaxis in patients in whom delivery is imminent.
4. Should we screen for Bacterial Vaginosis (BV) in women at
risk for preterm delivery?
Pregnant women at risk for preterm delivery may be
screened for BV during the first or early second
trimester according the Centers for Disease Control and
Prevention guidelines, but studies have shown mixed
results.
5. Progesterone to reduce preterm birth
Any women with a prior preterm delivery should
strongly be considered for weekly IM injections of 17
alpha-hydroxyprogesterone caproate (17P) starting at
16-20 weeks and ending in 36 weeks. IM progesterone
shows a significant reduction in all races for preterm
birth, low birth weight, intraventricular hemorrhage,
necrotizing enterocolitis, NICU admissions and the need
for supplemental oxygen therapy, while a four-year
follow-up found no adverse health outcomes of the
children.
Although other forms or routines of progesterone have
been studied (especially vaginal dosing, which would be
easier to accomplish), the results have been mixed, with
some studies showing improvements while others did
not.


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
Twin gestation did not show the same benefits as
singleton pregnancies on IM progesterone.
IM progesterone may be considered in the future for
those women whose cervix is 15mm and with a +fFN,
but more studies need to be done.

GESTATIONAL DIABETES MELLITUS (GDM)
SCREENING
1. Screen for undiagnosed Type II diabetes at the first prenatal visit in those with risk
factors, using standard diagnostic criteria.
a. Overweight (BMI 25 kg/m
2*
) and have additional risk factors:
i. Physical inactivity
ii. First-degree relative with diabetes
iii. High-risk race/ethnicity (e.g., African American, Latino, Native American,
Asian American or Pacific Islander)
iv. Women who delivered a baby weighing > 9 lbs. or who were diagnosed with
Gestational Diabetes Mellitus (GDM)
v. Hypertension ( 140/90 mmHg) or on therapy for hypertension
vi. HDL cholesterol level < 35 mg/dl (0.90 mmol/l) and/or a triglyceride level
> 250 mg/dl (2.82 mmol/l)
vii. Women with Polycystic Ovarian Syndrome (PCOS)
viii. A1C 5.7%, IGT or IFG on previous testing
ix. Other clinical conditions associated with insulin resistance (e.g., severe
obesity, acanthosis nigricans)
x. History of cardiovascular disease

2. In pregnant women not known to have diabetes, screen for GDM at 24-28 weeks
gestation using either a 50 gram one hour glucose challenge test or a 75 gram glucose
tolerance test. When using the 50-gram glucose challenge test, a value of 130-140 mg/dl
is considered abnormal and requires a 3-hour Glucose Tolerance Test (GTT) for
diagnosis. A value of 130 mg/dl has a sensitivity of 90% while 140 mg/dl reveals a
sensitivity of 80%. The 75-gram glucose tolerance test is a diagnostic test.

3. Screen women with GDM for persistent diabetes 6-12 weeks postpartum.


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13

4. Women with a history of GDM should have lifelong screening for the development of
diabetes or prediabetes at least every three years.
*At risk BMI may be lower in some ethnic groups

DIAGNOSIS OF GESTATIONAL DIABETES
Table 1: Diagnosis of GDM with 75-g oral glucose load (test is positive when any single
value is met or exceeded)
Status
Fasting 92 mg/dl 5.1 mmol/l
1-h 180 mg/dl 10.0 mmol/l
Source: Adapted from the American Diabetes Association. Diabetes Care. January 2011.
34 s15.

Table 2: Diagnosis of GDM with a 100-g oral glucose load (two or more of the values
must be met or exceeded for a positive diagnosis)
Status
Fasting 95 mg/dl 5.3 mmol/l

Source: ACOG, Practice Bulletin Number 30 (September 2001). Reaffirmed 2010.
Based on MFM committee members and based on MFM practice patterns and
community standards of care. Both American Diabetes Association (ADA) and ACOG
strategies would apply. The diagnostic test specific for pregnancy and about which the
greatest body of data exists is the 100-g, 3-hour oral GTT. Most practitioners providing
obstetrical care are familiar with this test. Others may choose to adopt the newer
recommendations by the ADA.


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13

MANAGEMENT OF GDM
Once GDM is diagnosed, what is the next step?
The ADA diet is given, nutritional counseling and an exercise program is started. Finger
sticks (fasting and 2-hour postprandial) should be done daily, recorded and then sent to
the physician weekly.
If fasting blood sugars are consistently above 95-105 or postprandial are > 120, medical
therapy should be started. Blood glucose monitoring to include either 1- or 2-hour
postprandial BS monitoring with 1 hour values < or =120 and 2 hour value < or= 120
GDM A1 is gestational diabetes controlled with diet.
GDM A2 is gestational diabetes that is insulin- or oral hypoglycemic- controlled.

Diet Therapy
The ADA recommends an average of 30kcal/kg/d/based on pre-pregnant body weight
for non-obese individuals.
If obese (BMI > 30 pre-pregnancy), calorie restrictions of 30-33 percent (but no greater)
will improve pregnancy outcomes. However, avoid ketonuria by following weekly urine
dipsticks.

Antepartum Testing
GDM A1 good control is treated like any other pregnancy except kick counts start at 28
weeks and NSTs are initiated after 40 weeks. Ultrasound should be done only if
measuring larger.
GDM A2 should have monthly ultrasounds and twice weekly NSTs or weekly Biophysical
Profiles (BPPs) and Amniotic Fluid Indexes (AFIs)

When and how should delivery occur?
Deliver GDM A1 patients in good control as any other patient without complications
Deliver GDM A2 patients at 39 weeks. If delivering before 39 weeks, strongly consider an
amniocentesis unless clinically contraindicated.
Diet controlled (A1): Fetal evaluation per clinical indications. Deliver by 40 weeks (or
sooner if clinically indicated).
Insulin controlled (A2): Weekly BPP: one or two times weekly starting at 32 weeks (or


Created 11/06
Reviewed: 7/08; 8/10; 09/12
PPMPC: 02/17/09
OBMAC: 10/01/2012
MPC: 11/15/2012
PEC-ALL-0769-13
sooner if clinically indicated). Sonogram every three to four weeks for fetal growth.
Deliver at 39 weeks, if the fetus is mature (or sooner if clinically indicated).

REFERENCES AND RESEARCH MATERIAL
American Diabetes Association, Gestational Diabetes Mellitus, Diabetes Care 26
s103-s105 (2003).
American Diabetes Association, Diabetes Care 34 s15 (January 2011).
ACOG, Practice Bulletin Number 30 (September 2001). Reaffirmed 2010.
ACOG, Practice Bulletin Number 33 (June 2002). Reaffirmed 2010.
ACOG, Practice Bulletin Number 60 (March 2005). Reaffirmed 2010.
ACOG, Committee Opinion Number 435 (June 2009).
ACOG, Committee Opinion Number 455 (March 2010).
ACOG, Committee Opinion Number 475 (February 2011).
ACOG, Practice Bulletin Number 43 (May 2003). Reaffirmed 2011.
ACOG, Practice Bulletin Number 29 (July 2001). Reaffirmed 2008.

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