Maternity Care Update Slides - BCCFP

MATERNITY CARE UPDATE (COVID19 EDITION)

Dr. Preveena Dharmaraj, MD, CCFP Maternity Care Physician, BC Women’s Hospital and South Community Birth Program

DISCLOSURES AND ACKNOWLEDGEMENTS➤ No conflicts to disclose

I acknowledge that I live and work on the unceded and ancestral territories of the xʷməθkwəy̓əm (Musqueam), Sḵwx̱wú7mesh

(Squamish), and Səl̓ílwətaʔ (Tsleil-Waututh) peoples

OBJECTIVES➤ Review alterations to prenatal visit schedules due to pandemic

restrictions

➤ Review the investigations, counselling and visits recommended for prenatal care under 20 weeks

➤ Identify options and timelines for prenatal genetic screening

➤ Thinking to the future: special populations and maternity care

COVID19 AND PREGNANCY➤ Unclear if pregnant individuals are at more risk of acquiring SARS CoV2, or at more

risk of getting severe disease, however most (80%) experience mild to moderate symptoms

➤ Pregnant women can continue to work if asymptomatic and not a recent COVID-19 contact. They should use PPE precautions as appropriate for their work environment

➤ Pregnancy Outcomes: To date, limited information is available. Outcomes good in general with preterm labour being the most reported adverse pregnancy outcome, with rates proportional to severity of maternal illness

➤ Teratogenicity: currently no reported increased risk of congenital anomaly, though the number of reported cases is small

➤ If a pregnant person develops COVID-19 at any time in pregnancy, they need evaluation and enhanced fetal surveillance including monthly ultrasounds

➤ Reproductive Infectious Diseases Service at BC Women’s Hospital is available for phone consultation for health care providers of pregnant women with documented or suspected COVID-19 in pregnancy (604-875-2161)

Adapted from “Pregnancy: Care During covid19 pandemic” BCCDC <http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/pregnancy> and “SOGC Committee Opinion no. 400: Covid-19 and Pregnancy”

PRENATAL VISITS IN PANDEMIC TIMES➤ According to Perinatal Services BC:

“Antenatal visits During Pandemic” Perinatal Services BC <http://www.bccdc.ca/Health-Professionals-Site/Documents/COVID19_AntenatalVisitsDuringPandemic.pdf>

PRENATAL CARE <20 WEEKS➤ ADAPTED Schedule

(for practicality in FFS):

• Visit #1 (virtual) - 5-8 weeks

• Visit #2 (virtual) - 8-12 weeks

• Visit #3 (in person) - 16 weeks

• Visit #4 (in person OR virtual) - 20 weeks

VISIT #1 (VIRTUAL)➤ Questions:

• Pregnancy planned or unplanned? How are they feeling? • Home UPT pos? • Symptoms • Spontaneous conception or ART? • LMP, cycles regularity and length to calculate preliminary EDD • Substance use?

➤ Goals: • Confirm if patient would like to continue with pregnancy • Offer symptom management • Book dating ultrasound (8-13 weeks) • Counsel on folic acid supplementation (see appendix), nutrition, exercise • Harm reduction/referral for substance use • Start thinking about maternity care provider (RM/GP-OB/OBGYN)

If first encounter >8 weeks: • Counsel on genetic testing • Req for PNBW

NAUSEA AND VOMITING IN PREGNANCY• Common (50-80%) of pregnant people • 90% resolve by 20 weeks • Mixed etiology (consider screening for anxiety)

➤ Approach (non pharm): 1. Stop PNV/Fe supp - switch to folic acid alone 2. Small frequent meals with protein 3. Ginger capsules 250mg QID 4. Consider - more frequent visits (if anxiety component), acupuncture

➤ Approach (pharm): 1. Diclectin (work up to 1 tab AM, 1 tab lunch, 2 tabs QHS - can go up to 8 tabs daily

per SOGC) 2. H2 blocker (Ranitidine 150mg or Famotidine 20mg) 3. Gravol 50mg PO q4h 4. Metoclopramide 5-10mg PO q8h 5. Ondansetron 4-8mg PO q12h **review safety with patient

If ongoing: • Consider workup for alternative causes of N/V

PRENATAL BLOOD WORK➤ Other considerations:

• TSH based on risk factors (see below) if asymptomatic

• Toxo/parvo/CMV if exposure/symptomatic/high risk (HIV/immunosuppressed)

• Baseline LFTs for high BMI/strong family history of HTN

“Early Prenatal Care Summary” Perinatal Services BC <http://www.perinatalservicesbc.ca/Documents/Resources/Checklists/PSBC_Prenatal_Checklist.pdf>

HYPOTHYROID AND PREGNANCY

Adapted from “Thyroid Disease in Pregnancy” Dr. Sabrina Gill. OB Update for Family Physicians

TSH 0.1 - 2.5

Treat with levothyroxineConsider treatment

No further workup

CHECK TSH if risk factors

TSH 2.5 - 10 TSH >10

TPOAb negative

No treatment

TPOAb positive

Treat with levothyroxine

TSH 2.5 mU/L - ULRR

TSH ULRR - 10 mU/L

TSH ULRR - 10 mU/L

TSH 2.5 mU/L - ULRR

GBS BACTERIURIA IN PREGNANCY➤ Treat GBS to reduce risk of pyelo, low birth weight, preterm birth,

chorio, neonatal GBS disease

➤ Symptomatic GBS bacteriuria with any colony count: TREAT • Amoxicillin 500mg TID • Cephalexin 250 - 500mg QID • Nitrofurantoin 100mg BID (if <36w) • Cefixime 400mg PO daily • Fosfomycin 3g PO x 1 dose

• Test of cure should be done 10 days after completing treatment

➤ Asymptomatic GBS bacteriuria with HCC: TREAT (as above) • High colony count (HCC): ≥ 105 CFU/mL OR 108 CFU/L

➤ Asymptomatic GBS bacteriuria with LCC: do not treat • Low colony count (LCC): < 105 CFU/mL (100,000) OR 108 CFU/L

(100,000,000)

VISIT #2 (VIRTUAL)➤ Questions:

• Personal and family health history? • Social history and barriers? • Obstetrical history? • Last pap? • Special considerations to add to PNBW?

➤ Goals: • Choosing genetic screening options +/- book NT US • Req for PNBW • Review dating US to confirm EDD and book anatomy scan • ROR for previous births • Start considering any reasons for consults - anesthesia/OB/repro psych/medical

genetics

➤ Pandemic considerations: • Outline expected covid19 protocols with healthcare encounters • Check in re: finances/work, consider food insecurity • Check in re: mood and anxiety

GENETIC SCREENING➤ Looking for:

• Aneuploidy (trisomy 21/13/18) • ONTD (SIPS/IPS only)

➤ Considerations: For provider: • Maternal age at EDD • Gestational age • Singleton vs twin • Previous pregnancy

with trisomy 21/13/18

For patient: • Access • Cost • Performance of test


NIPT➤ Non invasive prenatal test/cell free DNA - placental DNA

➤ Performance for T21 is over 99% detection rates, 0.1% false positive rates

➤ Low fetal fraction (3-5%) seen in early gestation, high BMI, collection issues, aneuploidy resulting in need to redraw

➤ Can test for microdeletions however these are rare and as such specificity and sensitivity are low; not recommended to test for these at this time

➤ NIPT is funded for: • Positive SIPS/IPS/Quad • Risk of Down’s is >1/300 on screening or ultrasound

• 1. NTh ≥ 6 mm; 2. Echogenic bowel (brightness ≥ bone); 3. Absent nasal bone (second trimester); 4. Aberrant right subclavian artery; 5. More than one marker of aneuploidy (Needs Med Gen referral for risk assessment and authorization)

• Hx T13/21/18 in previous pregnancy

GENETIC SCREENING PERFORMANCE

GENETIC SCREENING DECISION TREE <14 WEEKS

➤ Next steps, if positive: • SIPS/IPS - patient will be given option for funded NIPT or to go straight to amnio • NIPT - option of CVS (<14 weeks) or amnio


MSP

Private Pay

<35

>35/twins/IVF-ICSI

Any age NIPT

COST MATERNAL AGE

>40 IPS or amnio

IPS (SIPS + NT US)

SIPS

WANTS TO SCREEN

ANXIETY DURING COVID19➤ Pregnancy can be anxiety provoking at baseline, we have seen an increase

in perinatal anxiety and depression reports since start of the pandemic ➤ Questions:

• How are things feeling in your pregnancy so far? How are you coping amidst the pandemic?

• Fill EPDS (Edinburgh Postnatal Depression Scale)

➤ Goals: • Identify and acknowledge symptoms • Connect with resources • Offer treatment

➤ Resources (see appendix for links): • Local Public Health Unit/RNs • Anxiety Canada • Counselling (private vs. psychology first aid) • Pacific Postpartum Support Society • Reproductive Mental Health

VISIT #3 (IN PERSON)➤ CPE:

• BP, BMI and FHR • Thyroid exam • Offer breast exam • Cardioresp - murmurs/EHS/wheeze • Skin - concerning lesions/varicose veins • MSK - scoliosis • + pap if due and BV swab if hx preterm birth

➤ Goals: • Confirm maternity care provider chosen and referral PRN • Ensure anatomy scan booked • Review PNBW • Review genetic screening if done • Does patient meet criteria to start ASA/Ca for pre-eclampsia prevention?

ASPIRIN IN PREGNANCY➤ Dose: 81mg once daily ➤ Goal is to prevent placental mediated complications (i.e. pre-eclampsia)

➤ SOGC says to initiate between 12-16 weeks (however ACOG cites benefit in starting up to 28 weeks) and to continue until 36 weeks GA

➤ Criteria differ slightly depending on source (NICE vs ACOG vs SOGC)In BC can use criteria from EMMA (Evaluating Maternal and fetal Markers of Adverse placental outcomes) Clinic at BCWH (next slide)

➤ Also add Calcium 1g/day if daily intake is <600mg/dayosteoporosis.ca has a calcium calculator:https://osteoporosis.ca/bone-health-osteoporosis/calcium-calculator/#page-1

“Low Dose Aspirin Use in Pregnancy” ACOG <https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/07/low-dose-aspirin-use-during-pregnancy>

ASPIRIN IN PREGNANCY

“EMMA Clinic Referral” BCWH <http://www.bcwomens.ca/Pregnancy-Prenatal-Care-Site/Documents/BCW%20EMMA%20Clinic%20referral.pdf>

LOOKING TO THE FUTURE: ANTI-RACISM AND MATERNITY CARE

➤ How do we cultivate an anti-racist maternity practice? • Race affects maternity outcomes in North America • Disparities are magnified by the pandemic, which has shown to

disproportionately affect racialized and marginalized populations • Multiple obstacles if language/trust/SES limitations

➤ Considerations: • Trauma-informed care • Consider our lens of what is “normal” - maternity care may look different in

different countries • Consider blocking longer initial appointments to allow time for questions, help to

navigate booking appointments • Consider using an interpreter • Write things down - numbered list of things to be done for next appointment

LOOKING TO THE FUTURE: ANTI-RACISM AND MATERNITY CARE

➤ Indigenous populations: • Cannot assume that our healthcare systems are directly transferrable to

Indigenous populations • Consider how colonization has impacted these communities and caused

inequalities, and how these have been amplified by the pandemic

ACTIONS: • Educate yourself - ex. San’yas Indigenous Cultural Safety Course - understand

the history to prevent re-traumatization • Be open to modifying practice and asking patients for guidance • Connect patients with resources: social workers for maternity care resources

including prenatal nutrition program, public health nurses, aboriginal health navigator

• Understand FNHA Health Benefits • Can apply for doula care (Doula for Aboriginal Families Grant Program) to allow

for continuity of care, trust relationship, cultural competency and advocacy through labour process

QUESTIONS

APPENDIX A: ANTENATAL TIMELINES CHEATSHEET

When Investigations

1st visitPNBW req (CBC, Group and screen, Rubella titer, RPR, HIV, Hep BsAg, urine culture, TSH, anti-HCV +/- extras), Genetic screening requisition Dating ultrasound requisition

8-12 weeks Dating ultrasound

9 to 13+6 weeks SIPS pt 1 (best between 10 and 11+6 weeks)

11 to 13+6 weeks NT ultrasound (>35yo)

15 to 20+6 weeks SIPS pt 2 (best between 15+2 and 16 weeks)

13+6 to 20 weeks QUAD screen (if presenting >13+6 weeks)

2nd visit Physical exam +/- pap/swabs

18-22 weeks Detailed ultrasound

APPENDIX B: FOLIC ACIDPER SOCG Guidelines: ➤ LOW RISK

• 0.4mg/day

➤ MODERATE RISK

• 1mg/day until 12 weeks, then 0.4mg/day

➤ HIGH RISK

• 4g/day (practically can take 5mg pill for ease)

APPENDIX C-1: RESOURCES FOR PROVIDERS➤ Early Prenatal Care Summary and Checklist: http://

www.perinatalservicesbc.ca/Documents/Resources/Checklists/PSBC_Prenatal_Checklist.pdf

➤ EDD Calculator: http://www.perinatalservicesbc.ca/health-professionals/professional-resources/edd-calculator

➤ Genetic Screening Information: http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/PrenatalScreeningGuideline.pdf

➤ Maternity Care Pathway: http://www.perinatalservicesbc.ca/Documents/Guidelines-Standards/Maternal/MaternityCarePathway.pdf

➤ SOGC Folic Acid Guideline: https://www.jogc.com/article/S1701-2163(15)30230-9/pdf

APPENDIX C-2: RESOURCES FOR PATIENTS➤ CFPC Pregnancy Handout: https://portal.cfpc.ca/resourcesdocs/

uploadedFiles/Resources/Resource_Items/Patients/PatInfoBro_Pregnancy_EN.pdf

➤ Perinatal Services BC: http://www.perinatalservicesbc.ca/health-info/pregnancy

➤ Genetic Screening Info: http://www.bcprenatalscreening.ca ➤ Baby’s Best Chance Booklet: https://www.healthyfamiliesbc.ca/about-

us/additional-resources

➤ OMama (Ontario): https://www.omama.com/en/index.asp

➤ Pregnancy Vancouver: https://pregnancyvancouver.ca/ ➤ Food Safety in Pregnancy: https://www.healthlinkbc.ca/healthy-eating/

pregnancy-food-safety

➤ Analgesia in Labour: labourpains.com

APPENDIX C-3: COVID19 RESOURCES➤ Pregnancy Vancouver: https://pregnancyvancouver.ca/covid-19-

pregnancy/

➤ Pandemic Pregnancy Guide (by a group from St. Mike’s in Toronto): https://drive.google.com/file/d/1b4dNi2oNvxb79hU8VAuGBqYdT0sb-zy6/view

➤ BC CDC General Guidelines for Community Providers: http://www.bccdc.ca/Health-Professionals-Site/Documents/Pregnancy-COVID19-Community-Providers.pdf

APPENDIX C-4: MENTAL HEALTH RESOURCES➤ Anxiety Canada: https://www.anxietycanada.com/articles/what-to-do-if-

you-are-anxious-or-worried-about-coronavirus-covid-19/

➤ Psychology First Aid (free): https://www.psychologists.bc.ca/covid-19-resources

➤ Pacific Post Partum Support Society: http://postpartum.org/

➤ Here to help: https://www.heretohelp.bc.ca/infosheet/postpartum-depression

➤ BC Reproductive Mental Health: https://reproductivementalhealth.ca/

➤ EPDS in multiple languages: http://www.perinatalservicesbc.ca/health-professionals/professional-resources/health-promo/edinburgh-postnatal-depression-scale-(epds)

APPENDIX C-4: ANTI-RACISM RESOURCES➤ Spoken Language Interpreter: http://www.phsa.ca/health-professionals/

professional-resources/interpreting-services#Access--interpreters

➤ Healthiest Babies Possible: http://www.vch.ca/locations-services?search_term=Healthiest+Babies+Possible+Program*

➤ Health Care System Navigation: https://patienteduc.fraserhealth.ca/file/finding-your-way-around-our-health-care-system-a-g-229674.pdf

➤ Pacific Immigrant Resource Society: https://pirs.bc.ca/ ➤ San’yas Indigenous Cultural Safety Training: http://www.sanyas.ca/

➤ FNHA Doula Program: https://www.fnha.ca/wellness/wellness-for-first-nations/women-men-children-and-families/doula-services

➤ Aboriginal Health Navigator: http://www.vch.ca/Locations-Services/result?res_id=771

➤ Directory of BIPOC Counsellors: www.healingincolour.com