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by interprofessional team members such as physicians, registered nurses, lactation consul-tants, nutritionists, social workers, therapists, psychologists or psychiatrists, and health edu-cators in addition to, or instead of, nurse practi-tioners and nurse-midwives (Mac Arthur et al., 2003). 2. M edications and therapeutics a. C ontinue daily prenatal vitamins or multivitamin during lactation if diet is lacking in whole foods, variety and balance (AAP & ACOG, 2012). b. Othe r medications as warranted by subjective and objective data (e. g., stool softener, analgesics, antibiotics). c. C onsider recommending or supplying vaginal lubricant due to vaginal dryness commonly reported during lactation. d. V accinations such as influenza and T dap (if not given during pregnancy); measles, mumps, rubella; varicella; or hepatitis A and B vaccines, with reminders and follow-up appointments as required for series. e. C ontraception initiation will depend on lacta-tion, desired method, and timing of resump-tion of sexual activity. Contraceptive methods and return to fertility are included in antepar-tum teaching to ensure informed consent and develop a postpartum implementation plan in advance. i. Es trogen-containing hormonal contraception is not generally recommended until 6 weeks postpartum, because of the increased risk of venous thromboembolism secondary to the resolving hypercoaguable state of pregnancy (Speroff & Mishell, 2008). In addition, there are some concerns about estrogen affecting milk supply, although research findings are inconclusive (T epper, Phillips, Kapp, Gaffield, & Curtis, 2015). ii. I f women have difficulty accessing care or managing their fertility, access to long-acting reversible contraceptives such as intrauter-ine devices or hormonal implants may be provided in the immediate postpartum peri-od to avoid the risk of unintended pregnancy (Speroff & Mishell, 2008). An immediate postpartum intrauterine contraceptive may be placed under ultrasound guidance follow-ing delivery of the placenta. Although expul-sion rates are higher following placement immediately versus 4-8 weeks postpartum, pregnancy prevention is effective when the device is retained. E. Family planning: Provide families access to desired contraception and encourage a healthy pregnancy interval. F. Identify and address health education, maintenance, and primary care needs; provide or refer as indicated by availability of services. V. Plan A. Diagnostics 1. L aboratory testing as indicated by history or examination, for example a. U rine dipstick to assess for protein or nitrites if hypertensive or symptomatic for urinary tract infection b. U rine culture and sensitivity to rule out urinary tract infection c. C omplete blood count to assess for infectious processes or anemia d. W et mount to assess for vaginitis or infection e. S exually transmitted infection testing f. P ostpartum screening for women with diagnosis of gestational diabetes in pregnancy, e. g., a 2-hour, 75 gram oral glucose tolerance test performed 6-12 weeks after delivery (Leuridan et al., 2015). 2. W omen's health screening as indicated a. P ap smear b. O ccult fecal blood c. M ammography if not breastfeeding d. S creening tests indicated by age or health history, such as hemoglobin or lipid profile (results con-founded by breastfeeding) B. Treatment and follow-up 1. V isit schedule and providers a. D aily inpatient postpartum visits by a maternity or primary care provider is standard, with out-patient follow-up one or more times, 1-8 weeks later (Haran et al., 2014) b. Ea rly or repeated outpatient visits or telephone consultations may be indicated for women who experienced obstetrical complications or have adverse health conditions or other risk factors for postpartum complications (Lavender et al., 2013). c. V isits should be conducted by competent and qualified providers, ideally with access to medi-cal records if continuity of care is not feasible or desired by the patient. Visits may be performed 272 CHAPTER 29 | The Postpartum Visit
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iii. W omen may benefit from a prescription for emergency contraception in case of contra-ceptive failure. f. The rapeutics for postpartum conditions or com-plications, including i. Di scomfort from genital edema and perineal laceration is often treated with application of witch hazel, topical analgesia, local cooling with ice or gel packs (Minassian & Jazayeri, 2002; Moore & James, 1989), and/or hydro-therapy sitz baths, which are thought to promote healing as well as comfort despite limited supportive data (Aderhold & Perry, 1991; East, Begg, Henshall, Marchant, & Wallace, 2012). Complementary therapies commonly used for these purposes despite little to no evidence base include topical cas-tor oil and herbal perineal packs. ii. C ompression stockings and hydrotherapy may be considered for symptomatic vari-cosities. iii. A pe lvic brace or binder may reduce dis-comfort from pelvic girdle pain or symphy-sis pubis mobility and separation. In severe cases, a walker or cane may be indicated. C. Patient education 1. A nswer questions and address concerns of the post-partum woman and her family, which often include a. C larifying questions about the labor and birth experience, and any impact of complications or procedures on future health or childbearing (Declercq et al., 2013) b. R ecovery after cesarean birth (AWHONN, 2006; Tharp & Farley, 2013)i. P ostoperative self-care and pain management ii. A lternate infant feeding positions per maternal comfort, e. g., football hold (infant is not on incision) or side-lying (abdominal muscles are not engaged through feeding) iii. P ossible discomforts from surgery or anes-thesia, e. g., edema and constipation iv. S urgical complications such as excessive blood loss, thrombophlebitis, oliguria, and infection of the surgical wound, uterus, or urinary tract v. The cho ice between vaginal birth after cesar-ean and elective repeat cesarean birth in future pregnancies is multifactorial and can be deferred in the postpartum period with referral to informational resources and future obstetrical care providers if applicable. In most cases, women with one or two prior cesareans may be counseled to consider vaginal birth after cesarean (ACOG, 2010). c. R eturn to normal daily activities, exercise, and work. d. I nfant care including feeding, soothing, pediatric visits, immunizations, circumcision, and safety measures such as sleeping arrangements and car seats e. W omen experience many postpartum physical changes (Cheng & Li, 2008) that may be unex-pected or concerning and prompt questions about normal versus abnormal symptoms, e. g., average versus excessive bleeding (soaking a large menstrual pad in 1 hour or less), breast pain from engorgement (bilateral) versus mastitis (usually signaled by unilateral mass with fever), etc. f. S exual health and dysfunction, which are critical topics but frequently omitted from postpartum visits (Declerq et al., 2013)i. S exual practices, libido, arousal, and orgasm ii. D yspareunia, frequently related to genital laceration and insufficient lubrication relat-ed to postpartum hormonal changes and breastfeeding iii. P ostpartum and other changes in psycho-logic aspects of sexuality including self-perception and partner relationships g. R eturn of fertility and menses h. C ontraception i. O ptimal pregnancy interval: although conclu-sive data are lacking, women may be advised that maternal and neonatal outcomes are improved when pregnancies are 18-60 months apart (Conde-Agudelo, Rosas-Bermúdez, & Kafury-Goeta, 2007) 2. C ounseling about nutrition and exercise is essential in the postpartum period, may have lifelong impact on all family members (Ruchat & Mottola, 2012), and may include: a. B asic principles of optimal nutrition and hydration b. E ncouragement to achieve and maintain a normal body mass index to reduce immediate and long-term health risks (Amorim, Linne, & Lourenco, 2013) c. Adv ice that regular exercise may improve health and prevent or reduce depressive symptomatol-ogy (T eychenne & Y ork, 2013) d. C ontinue daily 400-800 mcg folate throughout childbearing years for the prevention of neural tube defects in case of unintended pregnancy; dosage is adjusted according to maternal risk factors up to 4-5 mg per day (Gomes, Lopes, & Pinto, 2015)273 Plan
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b. I nfection or dehiscence of surgical site or peri-neal laceration site c. E xcessive or prolonged vaginal bleeding d. B reast abscess e. P ostpartum thyroiditis f. C hronic medical conditions requiring follow-up, if outside of the advanced practice nurse's scope of practice g. I ntimate partner violence h. P oor maternal adaptation i. P ostpartum depression, anxiety, mania, or psychosis j. S ubstance abuse treatment k. S uspected child abuse or neglect (notify pedia-trician and child protective services) l. H ousing, food, and financial assistance programs 2. L ocal and web-based resources a. P ublic health programs, visiting nurses asso-ciations, lactation consultants, nutritionists, breastfeeding and birth trauma support groups, therapists, social workers, psychologists, psychi-atrists, and postpartum doulas may have services for the evaluation, monitoring, and treatment of select maternal physical and psychosocial prob-lems and infant or breastfeeding concerns. b. W omen can be encouraged to seek support groups and other services for new parents, par-ticularly if they lack family and social support, experienced childbirth-related trauma, or have special circumstances such as multiples or perina-tal loss. Online forums may be a useful adjunctive or primary source of meaningful support if local resources are limited, particularly for women with unusual diagnoses or infants with rare con-ditions that are not addressed by programs in the community. 3. P rimary care: Women and their families need a medical home for ongoing health maintenance. This might be a nurse practitioner or midwife-led practice setting, a community clinic, or other primary care location. Postpartum clients may be guided to access ongoing healthcare elsewhere if they will not remain in your practice beyond the postpartum period. Midwives and nurse practitioners are uniquely situ-ated to have a profound effect on the health of women and their families. The relationships we establish with our clients in the antepartum period, as we assist them to have the safest and healthiest pregnancies possible, provides the platform for further growth in the postpartum period. We can have an ongoing positive impact on the lives of our clients and their families, ideally resulting in intergenerational health promotion and improved public health. e. N utritional supplementation specific to the postpartum periodi. Fluid and fiber to support bowel function ii. I ron supplementation following postpar-tum hemorrhage or anemia diagnosis iii. R outine supplementation is not indicated in the absence of nutritional deficiencies, in which case a multivitamin including cal-cium and vitamins B and D may be helpful (AAP & ACOG, 2012) iv. Es sential fatty acids intake may minimize incidence and severity of postpartum depression in women and optimize brain development in breastfed infants (Genuis & Schwalfenberg, 2006; Wojcicki & Heyman, 2011) f. N utrition during breastfeeding (AAP & ACOG, 2012)i. M inimal daily caloric intake required for milk production in the average woman is 1,800, with 500 calories typically used for this purpose each day ii. W eight loss of 2 pounds per month does not typically affect lactation iii. A lthough common, routine vitamin supple-mentation is not indicated during lactation if a woman's diet is wholesome, balanced, and varied, in the absence of identified deficiencies 3. Add itional health maintenance counseling should include a. S igns and symptoms that require immediate evaluation b. R esumption of routine gynecological and pri-mary care c. S elf-knowledge and examination (e. g., breasts and skin) d. Ke gel exercises for pelvic muscle tone, conti-nence, and sexual health e. I f urinary or fecal incontinence is present, advise this is not uncommon and is reported by 10-50% and up to 25% of postpartum women respectively (Handa et al., 2007). Pelvic floor muscle training, pessary fitting, and surgical intervention may be discussed if Kegel exercises do not result in improved symptoms within 1-2 months postpar-tum (Dumoulin & Hay-Smith, 2010). D. Consultation and referral as indicated 1. C onditions that warrant medical consultation or referral may include, and are not limited to (Tharp & Farley, 2013): a. E ndometritis274 CHAPTER 29 | The Postpartum Visit
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referen Ce S Aderhold, K. J., & Perry, L. (1991). Jet hydrotherapy for labor and postpartum pain relief. MCN, the American Journal of Maternal Child Nursing, 16(2), 97-99. American Academy of Pediatrics & American College of Obstetricians and Gynecologists. (2012). Guidelines for perinatal care (7th ed. ). Washington, DC: American College of Obstetricians and Gynecologists. American College of Obstetricians and Gynecologists. (2010). ACOG practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstetrics & Gynecology, 116, 450. Amorim, A. R., Linne, Y. M., & Lourenco, P. M. (2013). Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database of Systematic Reviews, 7, CD005627 Andersen, L. B., Melvaer, L. B., Videbech, P., Lamont, R. F., & Joergensen, J. S. (2012). Risk factors for developing post-traumatic stress disorder following childbirth: A systematic review. Acta Obstetricia et Gynecologica Scandinavica, 91(11), 1261-1272. Association of Women's Health, Obstetric and Neonatal Nurses, (2006). The compendium of postpartum care (2nd ed. ). Washington, DC: Author. Barimani, M., Oxelmark, L., Johansson, S., & Highland, I. (2015). Support and continuity during the first 2 weeks postpartum. Scandinavian Journal of Caring Sciences, 29(3), 409-17. Cerimele, J., Vanderlip, E., Croicu, C., Melville, J., Russo, J., Reed, S., et al. (2013). Presenting symptoms of women with depression in an obstetrics and gynecology setting. Obstetrics & Gynecology, 122(2), 313-318. Cheng, C.-Y., & Li, Q. (2008). Integrative review of research on general health status and prevalence of common physical health conditions of women after childbirth. Women's Health Issues, 18(4), 267-280. Conde-Agudelo, A., Rosas-Bermúdez, A., & Kafury-Goeta, A. C. (2007). Effects of birth spacing on maternal health: A systematic review. American Journal of Obstetrics and Gynecology, 96(4), 297-308. Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to mothers III: New mothers speak out. New Y ork: Childbirth Connection. Dennis, C. L., Fung, K., Grigoriadis. S., Robinson, G. E., Romans, S.,  & Ross, L. (2007). T raditional postpartum practices and rituals: A qualitative systematic review. Women's Health, 3(4), 487-502. Di Bari, J. N., Yu, S. M., Chao, S. M., & Lu, M. C. (2014). Use of postpartum care: Predictors and barriers. Journal of Pregnancy, 2014, 530769. Dumoulin, C., & Hay-Smith, J. (2010). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 1, CD005654. East, C. E., Begg, L., Henshall, N. E., Marchant, P., & Wallace, K. (2012). Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database of Systematic Reviews, 5, CD006304. Gamble, J., & Creedy, D. K. (2009). A counseling model for postpartum women after distressing birth experiences. Midwifery, 25(2), e21-e30. Genuis, S. J., & Schwalfenberg, G. K. (2006). Time for an oil check: The role of essential omega-3 fatty acids and maternal and pediatric health. Journal of Perinatology, 26, 59-65. Gomes, S., Lopes, C., & Pinto, E. (2015). Folate and folic acid in the pericon-ceptional period: Recommendations from official health organizations in thirty-six countries worldwide and WHO. Public Health Nutrition, 1-14. Haran, C., van Driel, M., Mitchell, B. L., & Brodribb, W. E. (2014). Clinical guidelines for postpartum women and infants in primary care: A system-atic review. BMC Pregnancy and Childbirth, 14, 51. Jackson, E., & Glasier, A. (2011). Return of ovulation and menses in postpartum nonlactating women: A systematic review. Obstetrics & Gynecology, 117(3), 657-662. Lavender, T., Richens, Y., Milan, S., Smyth, R., & Dowswell, T. (2013, July 18). T elephone support for women during pregnancy and the first six weeks postpartum. Cochrane Database of Systematic Reviews, 7, CD009338. Leuridan, L., Wens, J., Devlieger, R., Verhaeghe, J., Mathieu, C., & Benhalima, K. (2015). Glucose intolerance in early postpartum in women with gestational diabetes: Who is at increased risk? Primary Care Diabetes, 9(4), 244-252. Mac Arthur, C., Winter, H. R., Bick, D. E., Lilford, R. J., Lancashire, R. J., Knowles, H., et al. (2003). Redesigning postnatal care: A randomised controlled trial of protocol-based midwifery-led care focused on individual women's physical and psychological health needs. Health T echnology Assessment, 7(37), 1-98. Minassian, V., & Jazayeri, A. (2002). Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain. Obstetrics & Gynecology, 100(6), 1239-1243. Minig, L., T rimble, E. L., Sarsotti, C., Sebastiani, M. M., & Spong, C. Y. (2009). Building the evidence base for postoperative and postpartum advice. Obstetrics & Gynecology, 114(4):892-900. Moore, W., & James, D. K. (1989). A random trial of three topical analgesic agents in the treatment of episiotomy pain following instrumental vagi-nal delivery. Journal of Obstetrics & Gynaecology, 10(1), 35-39. Rowan, C., Bick, D., & Bastos, M. H. (2007). Postnatal debriefing interven-tions to prevent maternal mental health problems after birth: Exploring the gap between the evidence and UK policy and practice. Worldviews on Evidence-Based Nursing, 4(2), 97-105. Rowlands, I. J., & Redshaw, M. (2012). Mode of birth and women's psycho-logical and physical wellbeing in the postnatal period. BMC Pregnancy and Childbirth, 12, 138. Ruchat, S. M., & Mottola, M. F. (2012). Preventing long-term risk of obesity for two generations: Prenatal physical activity is part of the puzzle. Journal of Pregnancy, 2012, Article ID 470247. doi:10. 1155/2012/470247. Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2015). Midwife-led continuity models versus other models of care for child-bearing women. Cochrane Database of Systematic Reviews, 9, CD004667. Shaw, E., Levitt, C., Wong, S., & Kaczorowski, J. (2006). Systematic review of the literature on postpartum care: Effectiveness of postpartum sup-port to improve maternal parenting, mental health, quality of life, and physical health. Birth, 33(3), 210-220. Speroff, L., & Mishell, D. (2008). The postpartum visit: It's time for a change in order to optimally initiate contraception. Contraception, 78(2), 90-98. Stevens-Simon, C., O'Connor, P., & Bassford, K. (1994). Incentives enhance postpartum compliance among adolescent prenatal patients. Journal of Adolescent Health, 15(5), 396-399. T epper, N. K., Phillips, S. J., Kapp, N., Gaffield, M. E., & Curtis, K. M. (2015, May 19). Combined hormonal contraceptive use among breastfeed-ing women: An updated systematic review. Contraception. doi: 10. 1016 /j. contraception. 2015. 05. 006 T eychenne, M., & Y ork, R. (2013). Physical activity, sedentary behavior, and postnatal depressive symptoms: A review. American Journal of Preventive Medicine, 45(2), 217-227. 275 References
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Wojcicki, J. M., & Heyman, M. B. (2011). Maternal omega-3 fatty acid supplementation and risk for perinatal maternal depression. Journal of Maternal, Fetal and Neonatal Medicine, 24(5), 680-686. Y onemoto, N., Dowswell, T., Nagai, S., & Mori, R. (2013, July 23). Schedules for home visits in the early postpartum period. Cochrane Database of Systematic Reviews, 7, CD009326. Tharp, N., & Farley, C. (2013). Clinical practice guidelines for midwifery and women's health (4th ed. ). Sudbury, MA: Jones & Bartlett Publishing. Thomson, G., Dykes, F., Hurley, M. A., & Hoddinott, P. (2012). Incentives as connectors: Insights into a breastfeeding incentive intervention in a disadvantaged are of North-West England. BMC Pregnancy and Childbirth, 12, 22. 276 CHAPTER 29 | The Postpartum Visit
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musculoskeletal, pulmonary, gastrointestinal, and renal sys-tems; and specific psychiatric diagnoses, infectious diseases, malignancies, and abnormal diagnostic testing (Office of T echnology Assessment, 1986). A. Perinatal risk factors and complications include, but are not limited to: 1. H istory of pregnancy or childbirth complications a. Ge stational diabetes, hypertensive disorder, or other pregnancy complication b. H abitual abortion (< 12-20 weeks gestation), stillbirth (≥ 20 weeks gestation) or death of a newborn or infant in the first year of life c. L arge or small for gestational age infant d. P reterm delivery e. D ystocia, maternal or neonatal birth injury, post-partum hemorrhage, or other complication of parturition f. P revious cesarean section or other uterine surgery 2. V ariants and complications of current pregnancy and parturition a. P renatal diagnosis of minor or major fetal anomaly b. M ultiple gestation c. N onvertex fetal presentation at term or fetal mal-presentation incompatible with vaginal birth d. P rolonged pregnancy (41-42 weeks gestation) or postterm pregnancy (≥ 42 weeks gestation) e. P reterm labor or ruptured membranes before term (20-36 weeks gestation) f. P rolonged premature rupture of membranes at term g. P olyhydramnios or oligohydramnios h. A bnormal placentation (e. g., previa or accreta) i. U nexplained vaginal bleeding j. R hesus factor sensitization or other Ig G anti-body sensitization k. H ypertensive disorders (essential or gestational hypertension, or preeclampsia-eclampsia)I. Intr oduction and general background Pregnant women are frequently dichotomized as being at “low” or “high” risk for suboptimal perinatal outcomes despite a con-tinuum of medical and obstetric risk. There is little disagree-ment as to what constitutes a normal pregnancy or physiologic childbirth in a healthy parturient, and nurse practitioners and nurse-midwives routinely provide independent care for these low-risk women (American College of Nurse-Midwives, Midwives Alliance of North America, & National Association of Certified Professional Midwives, 2012). At the other end of the spectrum are women for whom exclusive physician care and referral to perinatology or neonatology services is immedi-ately indicated due to high-risk medical conditions or unstable and severe complications of pregnancy and parturition. In the middle are women with one or more moderate risk factors, for whom informed consent for care and decisions about consulta-tion and referral to medical providers are unclear due to lack of relevant data from robust studies to guide clinical management including the selection of healthcare provider type (Chauhan, Hendrix, Berghella, & Siddiqui, 2010; Wright et al., 2011). Gray areas in clinical decision making necessitate partner-ship with women to develop care plans guided by their values, culture, and preferences for providers and care practices. Individual clinicians' past experience, skill set, values, and scope of practice also influence clinical decisions including consultations, collaborations, and referral. Additional influ-ential factors include state and federal regulatory language, institutional policies and interprofessional practice protocols, research findings, community standards, healthcare ethics, and financial considerations (Avery, 2000; Bailey, Jones, & Way, 2006; Porter, Crozier, Sinclair, & Kernohan, 2007). Within this complex context, nurse practitioners and nurse-midwives frequently collaborate with physician colleagues to care for pregnant women with perinatal risk factors for adverse out-comes and high-risk conditions including selected disorders of the endocrine, cardiovascular, hematologic, neurologic, Jenna Shaw-Battista Gu Idel Ine S for Med Ical c on S ultat I on, Interpro-fe SSI onal c olla B orat I on, and t ran S fer of c are d ur I n G p re G nancy and c h I ld BI rth© Eliks/Shutterstock; © donatas1205/Shutterstock 277 30Chapt Er
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14. C hild abuse or neglect, suspected or observed (notify pediatrician and child protective services) 15. N eonatal health conditions, anticipated or observed Figure 30-1 contains an algorithm for medical consultation and referral during pregnancy. Interprofessional practices ben-efit from applied algorithms in the form of clinical guidelines and written policies regarding methods and types of consul-tation and referral in their practice settings. These and other formal and informal strategies to encourage interprofessional communication and standardize collaborations may facilitate mutual understanding of varied scopes of practice and improve care team efficacy and job satisfaction along with patient out-comes (Bailey et al., 2006; Brooten et al., 2005; Hutchison et al., 2011; Kennedy, Grant, Shaw-Battista, Walton, & Sandall, 2010; Shaw-Battista, Fineberg, Skubic, Wooley, & Tilton, 2011; Zwarenstein, Goldman, & Reeves, 2009). Interprofessional guidelines for maternity care frequently describe consultation and comanagement of women with specific medical, obstetric, and neonatal risk factors. Varied levels of consultation may be delineated, with or without direct physical assessment and documentation of collabora-tive management plans required of the medical consultant for specific diagnoses. When pregnant women experience com-plications that require ongoing medical or obstetric manage-ment, comanagement or transfer of care to a physician rather than consultation may be indicated. High-risk patients may return to the nurse practitioner or nurse-midwife caseload for pregnancy or childbirth care if their condition stabilizes and collaborative or independent advance practice nursing care becomes feasible and mutually agreeable. For many childbearing women, risk status and maternity care provider type are determined by the severity rather than presence of a specific condition. For example, nurse practi-tioners and nurse-midwives may independently or collab-oratively care for women with gestational diabetes who can maintain euglycemia with diet and exercise or oral hypogly-cemic agents, but comanage care with obstetrician colleagues if insulin becomes necessary or transfer care to physicians if blood sugars are poorly controlled regardless of treatment type (Avery, 2000; Jacobson et al., 2005; Nicholson et al., 2009). Similarly, collaborative practice guidelines may suggest transfer to physician care when women have severe hyper-tensive disorders of pregnancy or require pharmacological treatment (e. g., antihypertensive medications or magnesium sulfate for seizure prophylaxis), but endorse independent advance practice nursing care or interprofessional coman-agement of women with mild or stable gestational hyperten-sion or preeclampsia (e. g., no pharmacological treatment is required, or the physician provides medication management while the nurse practitioner or nurse-midwife continues other aspects of maternity care) (Chummun, 2009). These details, and other specifics of clinical protocols and collaborative l. H emolysis, elevated liver enzymes, and low platelets syndrome m. I diopathic thrombocytopenic purpura n. C holestasis of pregnancy o. P reexisting or gestational diabetes mellitus p. S elected anemias or hemoglobinopathies(e. g., thalassemias and hemoglobin less than 10 g/d L, not responsive to iron therapy) q. S ickle cell crisis 3. S elected maternal infections with potential fetal sequelae (e. g., human immunodeficiency virus, cytomegalovirus, parvovirus, rubella, syphilis, toxo-plasmosis, primary herpes infection, or presence of genital lesions at term) 4. Add itional maternal illnesses (e. g., unstable new or chronic health conditions, severe asthma requiring hospitalization during pregnancy, autoimmune disorders, cardiac disease other than asymptomatic mitral valve prolapse, renal disease or recurrent urinary tract infections, or thyroid disorders) 5. P sychosocial risk factors (e. g., psychiatric diagnoses, substance abuse, interpersonal violence, social deprivation, poverty, and homelessness) B. Intrapartum and postpartum complications and procedures for which medical consultation, comanagement, or referral is recommended include: 1. P reterm labor and delivery 2. I nduction or augmentation of labor 3. A bnormal fetal surveillance and variant fetal heart rate tracings (category II and III) 4. A mnioinfusion 5. P rolapsed cord 6. C horioamnionitis or other maternal infection 7. P rodromal or protracted labor, or arrest of labor or fetal descent 8. A nticipated or actual shoulder dystocia 9. I ndications for, and occurrence of, operative vaginal delivery or cesarean section 10. S evere perineal laceration (third or fourth degree) or cervical laceration 11. P rolonged third stage of labor (> 30 minutes), with or without postpartum hemorrhage (> 500-1000 m L) 12. U nstable genitourinary hematoma 13. N ew maternal disease or exacerbation of chronic illness278 CHAPTER 30 | Guidelines for Perinatal Consultation, Collaboration and Referral
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practice agreements, necessarily differ among practice sites. Variation also occurs over time as interprofessional prac-tices evolve in response to changes in clinical team members, patient populations, and supportive data (Bailey et al., 2006; Zwarenstein et al., 2009). T able 30-1 contains a sample policy for community health center obstetric providers and high-risk obstetric physician consultation and transfer of care during pregnancy. Regardless of the indication for collaborative care, coman-agement must include ongoing communication among provid-ers to ensure patient safety (Bailey et al., 2006; Brooten et al., 2005; Zwarenstein et al., 2009). The structure of interprofes-sional communication varies among sites but typically includes periodic conversations about specific patients to achieve con-sensus about management plans via electronic medical record, telephone, secure email, or in person. Interprofessional prac-tices may use regularly scheduled meetings to discuss their high-risk prenatal caseload. This formalizes the comanage-ment process and ensures timely review of women's evolving health status to facilitate optimal outcomes. These interprofes-sional communications about risk assessment and plans of care should be documented prominently in the medical record in addition to routine charting following clinical encounters and any written consultant reports. Patients should be kept apprised of changing assessments, participate in formulating and revis-ing care plans, and receive information about healthcare pro-viders' responsibilities and relationships when consultation, comanagement or transfer of care occurs. In addition to formal interprofessional relationships, effec-tive communications, and shared clinical guidelines, optimal perinatal outcomes are fostered through collegial interactions that are characterized by mutual respect, professionalism, and trust (American College of Nurse-Midwives & American College of Obstetricians and Gynecologists, 2014). Shared goals related to high-quality patient-centered care, healthcare education, research, and public health may also strengthen interprofessional practice relations (Avery, Montgomery,  & Brandl-Salutz, 2012; Hutchison et al., 2011; King, Laros, & Parer, 2012; Shaw-Battista et al., 2011). Interprofessional clinical practices that include nurse practitioners and nurse-midwives contribute to public health by increasing access to safe and effective maternity care with comprehensive physi-ological and psychosocial support services, facilitation of normal childbirth, and decreased use of unnecessary costly obstetric interventions among childbearing women across the spectrum of health and perinatal risk (Cragin & Kennedy, 2006; Priddis, Schmied, Sneddon, & Dahlen, 2014). T o this end, public health policies and clinical organizations should Assessment by advanced practice nurse No significant risk factors identified One or more moderate risk factors identified High-risk condition identified Medical consultation Referral for medical care Risk factors are modifiable and/or resolved Patient condition is unstable Patient condition is stable Interprofessional co-management Advanced practice nursing care Medical management Figure 30-1 Algorithm for Medical Consultation and Referral During Pregnancy279 Introduction and general background
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Table 30-1 Sample Guidelines for Consultation and Referral During Pregnancy, San Francisco General Hospital Conditions Requiring High-Risk Obstetric Consultation Maternal Conditions Pelvic mass noted by physical exam or ultrasound Uterine malformations Patients with large fibroids in the lower uterine segment Maternal infections with potential fetal sequelae, e. g., toxoplasmosis, cytomegalovirus Recurrent pyelonephritis Nephrolithiasis Persistent proteinuria Persistent severe anemia with hematocrit < 28% despite iron therapy History of thromboembolic disease regardless of etiology Hypothyroidism Seizure disorder well controlled with medication Body mass index ≥ 45Fetal Conditions Intrauterine growth restriction with ultrasound-estimated fetal weight ≤ 10th percentile Fetal macrosomia with estimated fetal weight ≥ 95th percentile on ultrasound Oligohydramnios Polyhydramnios Any fetal structural abnormality detected by ultrasound Antibodies to C, c, D, Kell, E, e, or Duffy with titers < 1:8 Obstetrical History Recurrent pregnancy loss: History of ≥ 3 spontaneous abortions if under age 35, or ≥ 2 if over age 35 History of uterine cavity surgery other than cesarean birth Conditions Requiring Transfer of Care to High-Risk Obstetric Clinic Maternal Conditions Chronic hypertension diagnosed before pregnancy Hypertension in pregnancy requiring medication Active or uncontrolled seizure disorder Severe asthma with hospitalization for asthma during pregnancy Cardiac disease (except asymptomatic mitral valve prolapse) Pulmonary hypertension Platelet count less than 100,000 Deep vein thrombosis Sickle cell disease Lupus/scleroderma/any connective tissue disease Cancer Active tuberculosis Active viral hepatitis HIV positive Hyperthyroidism Diabetes: type 1, type 2, or poorly controlled gestational diabetes requiring medication Hyperemesis gravidarum with hospital admission, until resolved Paraplegia or quadriplegia Fetal Conditions Complete placenta previa or partial previa in the third trimester Chronic placental abruption diagnosed by hospital admission Presence of antibodies to C, c, D, Kell, E, e, or Duffy, with antibody titers ≥ 1:8 Multiple gestation Obstetrical History Incompetent cervix, or history suggestive thereof, i. e., painless cervical dilatation < 24 weeks gestation Other Conditions Transfer of care is recommended for the following conditions. However, in some cases, the benefits of continued client engaged in prenatal care at their original site may outweigh the benefits of services available in high-risk clinic. Active drug or alcohol use Mental illness characterized by the use of psychotropic medication, history of suicide attempts, violence, trauma, or hospitalization for psychiatric problems, with a probability of recurrence280 CHAPTER 30 | Guidelines for Perinatal Consultation, Collaboration and Referral
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Hutchison, M., Ennis, L., Shaw-Battista, J., Delgado, A., Myer, K., & Cragin, L. (2011). Great minds don't think alike: Collaborative maternity care at San Francisco General Hospital. Obstetrics & Gynecology, 118(3), 678-682. Jacobson, G. F., Ramos, G. A., Ching, J. Y., Kirby, R. S., Ferrara, A., & Field, D. R. (2005). Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization. American Journal of Obstetrics and Gynecology, 193(1), 118-124. Kennedy, H. P., Grant, J., Shaw-Battista, J., Walton, C., & Sandall, J. (2010). Normalizing birth: A study of childbirth in two NHS hospitals. Journal of Midwifery and Women's Health, 55(3), 262-269. King, T. L., Laros, R. K., & Parer, J. T. (2012). Interprofessional collaborative practice in obstetrics and midwifery. Obstetrics and Gynecology Clinics of North America, 39(3), 411-422. Nicholson, W., Bolen, S., Witkop, C. T., Neale, D., Wilson, L., & Bass, E. (2009). Benefits and risks of oral diabetes agents compared with insulin in women with gestational diabetes: A systematic review. Obstetrics and Gynecology, 113(1), 193-205. Office of T echnology Assessment. (1986). Health technology case study 37. Nurse practitioners, physician assistants, and certified nurse-midwives: A policy analysis. Washington, DC: Congress of the United States. Porter, S., Crozier, K., Sinclair, M., & Kernohan, W. G. (2007). New mid-wifery? A qualitative analysis of midwives' decision-making strategies. Journal of Advanced Nursing, 60(5), 525-34. Priddis, H. S., Schmied, V., Sneddon, A. & Dahlen, H. G. (2014, July 18). “ A patchwork of services”—Caring for women who sustain severe perineal trauma in New South Wales—from the perspective of women and midwives. BMC Pregnancy and Childbirth, 18(14), 236. Sakala, C., & Corry, M. P. (2008). Evidence based maternity care: What it is and what it can achieve. New Y ork, NY: The Milbank Memorial Fund. Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2013). Midwife-led continuity models versus other models of care for child-bearing women. Cochrane Database of Systematic Reviews, 8, CD004667. Shaw-Battista, J., Fineberg, A., Skubic, B., Wooley, D., & Tilton, Z. (2011). Collaborative maternity care: A successful model of public health and private practice partnership. Obstetrics & Gynecology, 118(3), 663-672. Wright, J. D., Pawar, N., Gonzalez, J. S., Lewin, S. N., Burke, W. M., Simpson, L. L., et al. (2011). Scientific evidence underlying the American College of Obstetricians and Gynecologists' practice bulletins. Obstetrics and Gynecology, 118(3), 505-512. Zwarenstein, M., Goldman, J., & Reeves, S. (2009). Interprofessional col-laboration: Effects of practice-based interventions on professional prac-tice and healthcare outcomes. Cochrane Database of Systematic Reviews, 3, CD000072. support nurse and midwife-led care, and interprofessional team-based care, as alternatives to conventional physician-led maternity care service models (Campbell, 2007; Hoope-Bender et al., 2014; Sakala & Corry, 2008; Sandall, Soltani, Gates, Shennan, & Devane, 2013). reference S American College of Nurse-Midwives & American College of Obstetricians and Gynecologists. (2014). Joint statement of practice relations between obstetrician-gynecologists and certified nurse-midwives/certified midwives. Washington, DC: American College of Nurse-Midwives. American College of Nurse-Midwives, Midwives Alliance of North America, & National Association of Certified Professional Midwives. (2012). Supporting health and normal physiologic childbirth: A consensus statement by ACNM, MANA and NACPM. Washington, DC: American College of Nurse-Midwives. Avery, M. D. (2000). Diabetes in pregnancy: The midwifery role in manage-ment. Journal of Midwifery & Women's Health, 45(6), 472-480. Avery, M. D., Montgomery, O., & Brandl-Salutz, E. (2012). Essential com-ponents of successful collaborative maternity care models: The ACOG-ACNM project. Obstetrics and Gynecology Clinics of North America, 39(3), 423-434. Bailey, P., Jones, L., & Way, D. (2006). Family physician/nurse practitioner: Stories of collaboration. Journal of Advanced Nursing, 53(4), 381-391. Brooten, D., Y oungblut, J., Blais, K., Donahue, D., Cruz, I., & Lightbourne, M. (2005). APN-physician collaboration in caring for women with high-risk pregnancies. Journal of Nursing Scholarship, 37(2), 178-184. Campbell, K. P. (Ed. ). (2007). Investing in maternal and child health: An employer's toolkit. Washington, DC: Center for Prevention and Health Services, National Business Group on Health. Chauhan, S. P., Hendrix, N. W., Berghella, V., & Siddiqui, D. (2010). Comparison of two national guidelines in obstetrics: American versus royal college of obstetricians and gynecologists. American Journal of Perinatology, 27(10), 763-770. Chummun, H. (2009). Hypertension: A contemporary approach to nursing care. British Journal of Nursing, 18(13), 784-789. Cragin, L., & Kennedy, H. P. (2006). Linking obstetric and midwifery practice with optimal outcomes. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(6), 779-785. Hoope-Bender, P. T., de Bernis, L., Campbell, J., Downe, S., Fauveau, V., Fogstad, H., et al. (2014). Improvement of maternal and newborn health through midwifery, The Lancet, 384(9949), 1226-1235. 281 References
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Section V co MMon o BStet Ric PRe Sent Ation Sfor TOL, her chances of success, her risk of uterine rupture, and risks and benefits for her and her baby (see Internet resources in section VI). Research shows that a woman's prior birth experience, perceived risk, fear and anxiety, opinions of family and friends, desire for planning and control, knowl-edge of birth options, and perceived provider preference significantly factor into her decision (Bernstein, Matalon-Grazi, & Rosenn, 2012; Shorten, Shorten, & Kennedy, 2014). It is also important to consider a client's health literacy as well as numeracy when reviewing statistics. It may be helpful to use visual aids such as an icon array (see Internet resources in section VI) to enhance understanding and reduce provider bias (Cox, 2014; Garcia-Retamero & Dhami, 2013). After a decision is made, a consent form should be completed and the process should be documented. Choices may be institution specific and a provider should know who in the obstetric com-munity offers TOL as an option. II. Risks and benefits of TOL versus repeat cesarean delivery A. Uterine rupture The risk of a uterine rupture for a woman choosing a TOL is 0. 47% (0. 2-0. 77%) (Dodd, Crowther, Huertas, Guise, & Horey, 2013; Guise et al., 2010). If a woman has had a pre-vious vaginal birth either before or after her cesarean birth this rate drops (Guise et al., 2010). If the prior cesarean was done within 24 months of the birth, the risk of rupture is slightly higher (Landon et al., 2004). Women with a his-tory of two prior LTCS have about a 2% risk of uterine rup-ture. If labor is being induced the rate of rupture increases to approximately 1. 1-1. 5% (NIH, 2010; Rossi & Prefumo, 2015). Labor augmentation with oxytocin does not seem to increase risk of uterine rupture (NIH, 2010; Ouzounian et al., 2011). There have been no reported maternal deaths caused by uterine rupture (NIH, 2010), although it is pos-sible that this is due to underreporting or failure to indicate I. Intr oduction and general background Because currently almost a third of births in the United States are by cesarean section, increasing numbers of women are faced with the choice of whether to have a repeat cesarean or a trial of labor (TOL) and attempt a vaginal birth after a cesarean (VBAC). Cesarean delivery rates in the United States have risen by almost 60% from a rate of 21% in 1996 to a record high of 32. 9% in 2009. In the last few years the rate has fallen slightly to 32. 7% in 2013 and 32. 2% in 2014 (Hamilton et al., 2015). For most of the 20th century, women who had a primary cesarean were advised to have subsequent cesarean deliv-eries. In 1980, the National Institute of Child and Human Development and the National Center for Health Care T echnology examined the evidence for this practice and out-lined recommendations for offering women a TOL. From 1980 to 1996 VBAC rates increased, but from 1996 to 2007 rates steadily declined from 28. 5% to 8. 3% and have sub-sequently risen to 20% in 2013 (Curtin, Gregory, Korst, & Uddin, 2015). Interestingly, for those women who choose to have a TOL, the rates of successful VBAC have remained steady at about 74% (Eden et al., 2012). In 2010 the National Institutes of Health (NIH) addressed the issue of declining availability and low VBAC rates at the Consensus Development Conference on Vaginal Birth After Cesarean. Their recommendation was that institutions offer TOL as an option to women with previous low trans-verse cesarean sections (LTCS) (NIH, 2010). The American Academy of Family Physicians (King et al., 2015), American College of Nurse-Midwives (2011), and American College of Obstetricians and Gynecologists (ACOG, 2010) have made the same recommendation. When helping women and families make the decision about their preferred mode of delivery, the practitioner must incor-porate principles of informed consent and shared decision making including assessing the woman's desires, her candidacy Rebekah Kaplan BIRTh Ch OICes f OR WOmen WIT h a P R ev IO us Cesa R ean De LI ve Ry© Eliks/Shutterstock; © donatas1205/Shutterstock 282 31Chapt Er
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blood transfusions, adhesions, and surgical injury all continued to increase (Marshall, Fu, & Guise, 2011). The long-term effects of urinary incontinence in women who have a VBAC versus cesarean birth are confounding, although mild incontinence may be higher in the short term for women who have a VBAC. Evidence shows lower rates of maternal morbidity in TOL clients with predicted VBAC success rates of greater than 60-70%. (ACOG, 2010; Grobman et al., 2009). E. Neonatal mortality Studies show that the neonatal mortality rate is higher for TOL at 1. 3 per 1,000 compared to elective repeat cesarean at 0. 5 per 1,000. The neonatal mortality rate for all first-time mothers is 1 per 1,000 (Guise et al., 2010; Smith, Pell, Cameron, & Dobbie, 2002). Neonatal death rates are higher in settings where rapid emergent cesarean sections cannot be performed. F. Neonatal morbidity Evidence indicates that infants born by cesarean have higher rates of respiratory distress syndrome, persistent pulmonary hypertension, transient tachypnea of the newborn, and need for oxygen and ventilator support than do infants born vaginally (NIH, 2010). Rates of hypoxic-ischemic encephalopathy in one study were 8 per 10,000 in the TOL group and none in the repeat cesarean group (Landon et al., 2004). G. Long-term consequences in offspring Evidence suggests that exposure to vaginal flora at birth is associated with the development of a healthy immune response. This is thought to be caused by microflora colo-nization of the neonatal intestinal tract, adaptive stress of labor and birth, and epigenetic regulation of gene expres-sion, each of which is altered in cesarean birth (Cho & Norman, 2013). Children and adults born by cesarean have a 20% increased risk of developing asthma and a 23% increased risk of developing type 1 diabetes (Cho & Norman, 2013). There is also greater prevalence of allergic rhinitis, food allergies, celiac disease, inflammatory bowel disease, and increased hospitalization for gastroenteritis in these children (Bager, Simonsen, Nielsen, & Frisch, 2012; Cho & Norman, 2013; Decker, Hornef, & Stockinger, 2011). An association between cesarean birth and obe-sity in childhood and young adulthood has also been cited in many studies (Li, Zhou, & Liu, 2013; Mesquita et al., 2013). H. Postpartum period Women recover more quickly, have less postpartum pain, and have shorter hospital stays after a vaginal birth ver-sus an operative birth. Mothers who have cesareans not only have a longer recovery but also delayed mother-infant interaction, lower rates of breastfeeding, and more rupture as the cause of death. Approximately 6% of uterine ruptures result in neonatal death (NIH, 2010). “ Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (study numbers range from 213-1,370) elective caesarean deliv-eries need to be performed to prevent one symptomatic uterine rupture” (Guise et al., 2004, p. 1). B. Risk for future pregnancies 1. P lacenta accreta and hysterectomy Women with multiple cesareans have an increased rate of placenta accreta and hysterectomy with each subsequent cesarean birth evidenced by many studies (ACOG, 2012; Marshall, Fu, & Guise, 2011). Some of the best evidence comes from Silver et al. (2006) who cited the incidence of placenta accreta from one previous cesarean to five or more: 0. 31%, 0. 57%, 2. 1%, 2. 3%, and 6. 7%; and the risk of hysterectomy from one previous cesarean to five or more: 0. 42%, 0. 90%, 2. 41%, 3. 49%, and 8. 99% (Marshall, Fu, & Guise, 2011; Silver et al., 2006). 2. Pl acenta previa The incidence of placenta previa significantly increases in women with each additional cesarean delivery occur-ring in 0. 9% who have one prior cesarean delivery, 1. 7% who have two prior cesarean deliveries, and 3%  in women who have three or more cesarean deliveries (NIH, 2010). Women with placenta previa having their third or greater cesarean have a much greater risk of hysterectomy (0. 7-4% versus 50-67%) as well as composite maternal morbidity (15% versus 83%) (Marshall, Fu, & Guise, 2011). C. Maternal mortality Overall numeric estimates of maternal death are 4 per 100,000 for women who undergo a TOL versus 13 per 100,000 for a repeat elective cesarean birth (Dodd et al., 2013; Guise et al., 2010). D. Maternal morbidity Overall, cesarean deliveries are associated with a 10% risk of morbidity including increased risk of infection (endo-metritis, urinary tract, or wound); thromboembolism; hysterectomy (2%); larger blood loss and severe postpar-tum hemorrhage (7. 3%); blood transfusion; and surgi-cal injury (e. g., injury to the bladder, ureter, or bowel). Women who have a TOL have a 4. 6% risk of infection versus 3. 2% in the elective repeat cesarean group, although the repeat cesarean group are more at risk for deep vein thrombosis and pulmonary embolism than the TOL group. The risks of hysterectomy, blood transfusion, and infection are similar in both groups, though evidence is confounding (Guise et al., 2010). In women with increas-ing numbers of cesarean births, the rates of hysterectomy, 283 Risks and benefits of TOL versus repeat cesarean delivery
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B. Objective 1. A ssess type of scar: on physical abdominal examina-tion, assess transverse or vertical skin scar, although skin incision does not reflect uterine incision. Iv. Goals for clinical management/ assessment A. Establish if the client is a candidate for TOL B. Individualize predicted success rate (Tables 31-1 and 31-2 ) C. Establish client's choice using principles of shared decision making v. Plan A. Attempt to obtain an operative report (Table 31-3 ). 1. T OL is not contraindicated with an unknown uterine incision unless there is a high clinical suspicion of a classical scar (ACOG, 2010; Smith et al., 2015). difficulty establishing breastfeeding. Women with cesarean births have less perineal or vaginal trauma and decreased urinary incontinence in the postpartum period. The maternal rehospitalization rate within 30 days is 2. 3 times higher in women with a cesarean birth (Declercq et al., 2007). According to Silver (2012), almost 20% of women reported chronic pain 3 months after their surgery, 12% a year after, and 33% had daily incisional pain at their surgery site 2 years after surgery. Pain as well as other morbidity increased with additional numbers of cesarean births (Miller, Hahn, & Grobman, 2013; Silver, 2012). III. Data collection A. Subjective: First visit 1. D ocument the reason for previous cesarean and events surrounding the birth. These include: a. R eason for prior cesarean (e. g., emergency cesarean birth for nonreassuring fetal heart trac-ing, placenta previa, arrest of descent, breech presentation) b. E mergent versus nonemergent surgery (emer-gent more likely to have a classical incision) (see T able 31-1) c. Ge stational age and fetal weight (early preterm more likely to have a classical incision) d. S tage of labor (cervical dilation and station) and length of labor e. F etal position, if possible (e. g., posterior) f. W here surgery was performed (e. g., small com-munity or major urban hospital) g. T ype of physician performing surgery (obstetri-cian, gynecologist, or general practitioner) h. F uture TOL: Did the physician advise the client whether or not she could attempt a TOL in the future? i. M aternal experience of previous labor and birth 2. N ote desired family size Table 31-1 VBAC Success Rates Indication for Prior Cesarean % s uccess Failure to progress 60-65% Nonrecurring conditions (placenta previa, breech)74-89% Fetal intolerance of labor 69-73% Body mass index > 40 52-70% See Internet VBAC success calculator for individual risk: http://www . bsc. gwu. edu/mfmu/vagbirth. html Table 31-2 Factors for VBAC Success Positive factors Maternal age < 40 Prior vaginal delivery (especially VBAC) Favorable cervical factors Presence of spontaneous labor Nonrecurring indication for previous cesarean (e. g., breech, previa) Greater maternal height Negative factors Increased number of prior cesarean deliveries Gestational age > 40 weeks Birth weight > 4,000 g Induction or augmentation of labor (63% success) Maternal obesity (body mass index > 30) Increased interpregnancy weight gain Gestational diabetes Maternal disease (e. g., hypertension) ACOG Practice Bulletin no. 115. (2010). Vaginal birth after previous cesarean delivery. National Institutes of Health Consensus Development Conference statement: Vaginal birth after cesarean: New insights. March 8-10, 2010. 284 CHAPTER 31 | Birth Choices for Women with a Previous Cesarean Delivery
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B. Educate on risks and benefits of repeat cesarean versus TOL: consider client desires, factors for success, and previous experience. C. Establish the client's understanding of benefits and risk. D. Use principles of shared decision making to ascertain client's choice. See section VI-Internet resources-Six steps of shared decision making. E. Have the client sign consent for her birth choice (Figure 31-1 ). (continues)f IGu Re 31-1 s ample Birth Choices after Cesarean Birth—Client Information and Choice form COMMUNITY HEALTH NETWORK OF SAN FRANCISCO Birth Choices After Cesarean Birth-Patient Information and Choice Form Page 1 of 2 NAME DOB MRN PCP Patient ID / Addressograph Even though you had a cesarean birth before, you may choose to try a vaginal birth or choose another cesarean birth for this pregnancy. There are both risks and benefits to trying a vaginal birth or choosing another cesarean. We want you to have the information that you need to make your choice. We want you and your baby to be healthy and we want you to feel good about your choice. Please read the information below and talk about it with your provider. 1. VAGINAL BIRTH ADVANTAGES Mothers who have vaginal births usually have less pain after the baby is born. Most recover faster and are able to go home sooner. There is less chance of getting an infection or needing a blood transfusion. Also, babies who go through labor have less breathing problems at birth. Finally, having a vaginal birth avoids the risks of having another cesarean (see number 4). Many women who had a cesarean can try a vaginal birth. Your chances of being able to have a vaginal birth depend on why you needed a cesarean before. Reasons that had to do with the baby, like breech position (bottom first) or having twins, might not happen again. Reasons that have to do with your body, like a small pelvis, could make a vaginal birth less likely. About 75% of women who had a cesarean before are able to have a vaginal birth with their next pregnancy. When you are in labor, your family or close friends can be with you. We will give you pain medicine if you want. We will watch you and your baby closely during labor. Sometimes the baby cannot be born through the vagina. If this happens, we will recommend another cesarean. Many women, however, try for a vaginal birth and are successful. Table 31-3 Relative Contraindications for T rial of Labor Previous cesarean birth with a uterine incision in the upper part of the uterus (“classical” incision), or low transverse uterine incision with an extension into the upper part of the uterus (active segment) Previous transfundal uterine surgery Previous uterine rupture Medical or obstetric complication that precludes vaginal birth Inability to perform emergency cesarean birth Content removed due to copyright restrictions285 Plan
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(continues)COMMUNITY HEALTH NETWORK OF SAN FRANCISCO Birth Choices After Cesarean Birth-Patient Information and Choice Form Page 2 of 2 NAME DOB MRN PCP Patient ID / Addressograph 2. CESAREAN BIRTH ADVANTAGES The main advantage of choosing another cesarean is that you have less risk of having the scar on your uterus open during labor which requires an emergency cesarean (see number 3). If you decide to have a cesarean, you avoid the chance of having labor and then still needing a cesarean. This could happen if your labor does not progress or if the baby shows signs of stress during labor. Women who try to have a vaginal birth but then need a cesarean during labor may have more surgical problems than women who choose a cesarean before labor begins. Also, if you choose to have another cesarean, you probably will not have labor pains. 3. VAGINAL BIRTH RISKS There is a small chance that the scar on your uterus from your cesarean could open up during labor. The risk of this happening depends on where your uterus was cut during your cesarean. If the scar from your cesarean is in the lower part of your uterus, the risk of it opening during labor is less than 1% (1 in 200). If you have had more than one cesar-ean or if your cesarean was recent (less than 2 years ago), the risk will be slightly increased that the scar could open during labor. If the scar is in the upper part of your uterus, there is much more risk that it could open in labor (as high as 10%). If you have a scar in the upper part of the uterus, we don't think you should try a vaginal birth. If your provider does not know where your uterus was cut, your risk of the scar opening during labor appears to be the same as those with a scar in the lower part of your uterus (<1%) as most women have cesareans with lower uterine scars. However, it could be as high as 10% if the scar is in the upper part of your uterus. If the scar on your uterus does open, you might need an emergency cesarean. You could bleed a lot and need a blood transfusion (blood from another person). You also could need a hysterectomy (removal of your uterus). There is a small chance that your baby or you could be injured or die. 4. CESAREAN BIRTH RISKS If you are able to have a vaginal birth you can avoid some of the risks of a cesarean. For every 100 women who choose a cesarean, about 10 will have a problem. Two women get a wound infection, 6 get a fever, 1 needs a blood transfu-sion, and less than 1 will have an injury to her intestines, bladder or blood vessels. For every 1,000 women who have a cesarean, about 2 will need a hysterectomy (removal of uterus), usually because of bleeding. The more times you have a cesarean, the more likely you are to have one of these problems. A cesarean can also cause scarring around the uterus. This scarring can make your next surgery more difficult. In another pregnancy, it can cause problems with the placenta and serious bleeding in a future pregnancy. Rarely, cesareans can weaken the uterus and the scar can open during another pregnancy. f IGu Re 31-1 s ample Birth Choices after Cesarean Birth—Client Information and Choice form (Continued) Content removed due to copyright restrictions286 CHAPTER 31 | Birth Choices for Women with a Previous Cesarean Delivery
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H. For clients choosing a cesarean delivery 1. C onsult with the physician obstetric team to schedule a cesarean at 39 weeks except for those with prior classical scars. a. Good dating: 39 weeks b. T wo prior cesareans: 39 weeks c. Kno wn classical scar: early term delivery F. If the client has an unknown scar, a consultation with a physician may be indicated in your site. G. For those choosing TOL 1. Di scuss with the client the care during her birth (continuous fetal monitoring, intravenous or saline lock). Consult per site guidelines. With induction of labor, the risk of uterine rupture increases and VBAC success decreases. If induction is indicated, the client needs to be recounseled. 5. I KNOW I CAN CHANGE MY CHOICE AT ANY TIME. Put your initials next to your choice. choose to try a vaginal birth choose another cesarean I understand the information on this paper. I talked to my pregnancy care provider about this information. I had all of my questions answered. Patient signature: Date: Print name Signature Counseling Provider: Date: Print name Signature Translator (if applicable): Date: Print name Signature Courtesy of Community Health Network of San Francisco, Department of Public Healthf IGu Re 31-1 s ample Birth Choices after Cesarean Birth—Client Information and Choice form (Continued) COMMUNITY HEALTH NETWORK OF SAN FRANCISCO Birth Choices After Cesarean Birth-Patient Information and Choice Form Page 3 of 3 NAME DOB MRN PCP Patient ID / Addressograph Content removed due to copyright restrictions287 Plan
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Curtin, S. C., Gregory, K. D., Korst, L. M., & Uddin, S. F. G. (2015). Maternal morbidity for vaginal and cesarean deliveries, according to previous cesarean history: New data from the birth certificate, 201. (National Vital Statistics Reports, Vol. 64, No. 4). Hyattsville, MD: Centers for Disease Control and Prevention, National Center for Health Statistics, U. S. Department of Health and Human Services. Decker, E., Hornef, M., & Stockinger, S. (2011). Cesarean delivery is associ-ated with celiac disease but not inflammatory bowel disease in children. Gut Microbes, 2(2), 91-98. Declercq, E., Barger, M., Cabral, H. J., Evans, S. R., Kotelchuck, M., Simon, C., et al. (2007). Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstetrics & Gynecology, 109(3), 669-677. Dodd, J. M., Crowther, C. A., Huertas, E., Guise, J. M., & Horey, D. (2013). Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth. Cochrane Database of Systematic Reviews, 12, CD004224-CD004224. Eden, K. B., Denman, M. A., Emeis, C. L., Mc Donagh, M. S. Fu, R., Janik, R. K., et al. (2012). T rial of labor and vaginal delivery rates in women with a prior cesarean. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 41(5),583-596 Garcia-Retamero, R., & Dhami, M. K. (2013). On avoiding framing effects in experienced decision makers. Quarterly Journal of Experimental Psychology, 66(4), 829-842. Grobman, W. A., Lai, Y., Landon, M. B., Spong, C. Y., Leveno, K. J., Rouse, D. J., et al. (2007). Development of a nomogram for prediction of vaginal birth after cesarean delivery. Obstetrics & Gynecology, 109(4), 806-812. Grobman, W. A., Lai, Y., Landon, M. B., Spong, C. Y., Leveno, K. J., Rouse, D. J., et al. (2009). Can a prediction model for vaginal birth after cesar-ean also predict the probability of morbidity related to a trial of labor? American Journal of Obstetrics and Gynecology, 200(1), 56e1-56e6. Guise, J., Denman, M. A., Emeis, C., Marshall, N., Walker, M., Fu, R., et al. (2010). Vaginal birth after cesarean: New insights on maternal and neonatal outcomes. Obstetrics and Gynecology, 115(6), 1267-1278. Guise, J. M., Mc Donagh, M. S., Osterweil, P., Nygren, P., Chan, B. K., & Helfand, M. (2004). Systematic review of the incidence and conse-quences of uterine rupture in women with previous caesarean section. British Medical Journal, 329(7456), 19-25. Hamilton, B. E., Martin, J. A., Osterman, M. J., & Curtin, S. C. (2015). Births: Preliminary data for 2014 (National Vital Statistics Reports, Vol. 64, No. 6). Hyattsville, MD: Centers for Disease Control and Prevention, National Center for Health Statistics, U. S. Department of Health and Human Services. Landon, M. B., Hauth, J. C., Leveno, K. J., Spong, C. Y., Leindecker, S., Varner, M. W., et al. (2004). Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. New England Journal of Medicine, 351(25), 2581-2589. Li, H. T., Zhou, Y. B., & Liu, J. M. (2013). The impact of cesarean section on offspring overweight and obesity: A systematic review and meta-analysis. International Journal of Obesity, 37(7), 893-899. King, V. J., Fontaine, P. L., Atwood, L. A., Powers, E., Leeman, L., Ecker, J. L., et al. (2015). Clinical practice guideline executive summary: Labor after cesarean/planned vaginal birth after cesarean. Annals of Family Medicine, 13(1), 80-81. Marshall, N. E., Fu, R., & Guise, J. (2011). Impact of multiple cesarean deliveries on maternal morbidity: A systematic review. American Journal of Obstetrics and Gynecology, 205(3), 262-268. v I. Internet r esources for providers, clients, and families A. VBAC Success Calculator (http://www. bsc. gwu . edu/mfmu/vagbirth. html) Enter data, such as maternal age, height, weight, ethnicity, and historical factors, to calculate the predicted chance of VBAC (based on Grobman et al., 2007). B. Childbirth Connection (http://www . childbirthconnection. org/): Organization promoting evidence-based maternity care and helping women and providers make informed deci-sions. Several sections regarding VBAC decision-making. C. Pictographs/Icon arrays (http://www. iconarray . com) Center for Bioethics and Social Sciences in Medicine  & Risk Science Center, University of Michigan. Create your own pictographs for use in VBAC counseling. D. NIH Consensus Development Conference on Vaginal Birth After Cesarean New insights (http://consensus. nih. gov/2010/vbac. htm). E. Informed Medical Decisions Foundation: Six steps of shared decision making for health care providers (Wexler, 2012) http://www. slideshare. net/fimdm/six-steps-of-shared -decision-making. Refe Ren Ces American College of Nurse-Midwives. (2011). Care for women desiring vaginal birth after cesarean. Journal of Midwifery & Women's Health, 56(5), 517-525. American College of Obstetricians and Gynecologists. (2010). ACOG practice bulletin no. 115: Vaginal birth after previous cesarean delivery. Obstetrics & Gynecology, 116(2, Pt. 1), 450-463. American College of Obstetricians and Gynecologists. (2012). ACOG committee opinion no. 529: Placenta accreta. Obstetrics & Gynecology, 120(1), 207-211. Bager, P., Simonsen, J., Nielsen, N. M., & Frisch, M.. (2012). Cesarean section and offspring's risk of inflammatory bowel disease: A national cohort study. Inflammatory Bowel Diseases, 18(5), 857-862. Bernstein, S. N., Matalon Grazi, S., & Rosenn, B. M. (2012). T rial of labor versus repeat cesarean: Are clients making an informed decision? American Journal of Obstetrics and Gynecology, 207(3), 204-206. Cho, C. E., & Norman, M. (2013). Cesarean section and development of the immune system in the offspring. American Journal of Obstetrics and Gynecology, 208(4), 249-254. Cox, K. J. (2014). Counseling women with a previous cesarean birth: T oward a shared decision-making partnership. Journal of Midwifery & Women's Health, 59(3), 237-245. 288 CHAPTER 31 | Birth Choices for Women with a Previous Cesarean Delivery
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Silver, R. M. (2012). Implications of the first cesarean: Perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. Seminars in Perinatology, 36(5), 315-323. Silver, R. M., Landon, M. B., Rouse, D. J., Leveno, K. J., Spong, C. Y., Thom, E. A., et al. (2006). Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology, 107(6), 1226-1232. Smith, D., Stringer, E., Vladutiu, C. J., Zink, A. H., & Strauss R. (2015). Risk of uterine rupture among women attempting vaginal birth after cesarean with an unknown uterine scar. American Journal of Obstetrics and Gynecology, 213(1), 80. Smith, G. C., Pell, J. P., Cameron, A. D., & Dobbie, R. (2002). Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. Journal of the American Medical Association, 287(20), 2684-2690. Wexler, R. (2012). Six steps of shared decision making for health care providers. Shared slides. Informed Medical Decisions Foundation. Retrieved from http://www. slideshare. net/fimdm/six-steps-of-shared-decision-making. Mesquita, D. N., Barbieri, M. A., Goldani, H. A., Cardoso, V. C., Goldani, M. Z., Kac, G., et al. (2013). Cesarean section is associated with increased peripheral and central adiposity in young adulthood: Cohort study. PLo S ONE, 8(6), e66827-e66827. Miller, E. S., Hahn, K., & Grobman, W. A. (2013). Consequences of a primary elective cesarean delivery across the reproductive life. Obstetrics and Gynecology, 121(4), 789-797. National Institutes of Health. (2010). NIH Consensus Development Conference statement on vaginal birth after cesarean: New insights. March 8-10, 2010. Obstetrics & Gynecology, 115(6), 1279-1295. Ouzounian, J. G., Miller, D. A., Hiebert, C. J., Battista, L. R., & Lee, R. H. (2011). Vaginal birth after cesarean section: Risk of uterine rupture with labor induction. American Journal of Perinatology, 28(8), 593-596. Rossi, A. C., & Prefumo, F. (2015). Pregnancy outcomes of induced labor in women with previous cesarean section: A systematic review and meta-analysis. Archives of Gynecology and Obstetrics, 291(2), 273-280. Shorten, A., Shorten, B., & Kennedy, H. P. (2014). Complexities of choice after prior cesarean: A narrative analysis. Birth, 41(2), 178-184. 289 References
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II. P oor quality of sleep Musculoskeletal discomfort, fetal movement, increased fre-quency of urination, increased appetite, nausea, and increased life stresses all contribute to poor quality of sleep during pregnancy. Women report poor quality of sleep in every trimester of pregnancy, including difficulty falling asleep and staying asleep and frequent waking. A. Subjective 1. T iming and severity of sleep disturbances 2. S ymptoms of depression and anxiety 3. S ources of stress 4. I mpact on daily functioning 5. C affeine and other stimulant intake 6. C urrent daily habits, including daily exercise and evening routine 7. S elf-treatment B. Goals for clinical management 1. S creen for underlying mood disorders in women with multiple or severe common discomforts. 2. A ssess quantity and quality of sleep in pregnant women. 3. E ducate pregnant women about sleep hygiene, circadian rhythms, and measures to improve sleep. C. Management T reatment approaches begin with education and behav-ioral changes. There is scant research specific to pregnancy and treatments for insomnia. Moderate exercise, such as daily brisk walking, has been demonstrated to be an effective treatment in other demographic populations (King, Oman, Brassington, Bliwise, & Haskell, 1997). There is some debate regarding whether exercise must occur before evening. I. Intr oduction to common discomforts of pregnancy Most women suffer considerably during a pregnancy. The normal physiologic changes of pregnancy affect all body systems and can cause symptoms that range from mildly uncomfortable to debilitating. These discomforts very rarely pose a risk to the well-being of the fetus. The degree of discomfort experienced by an individual woman is affected by diet, exercise, genet-ics, personal self-care habits (e. g., obtaining adequate sleep), mood, body image, level of stress, and social support. A preg-nant woman feels more satisfied and confident when her care provider listens to her concerns and treats her respectfully (Avery, Saftner, Larson, & Weinfurter, 2014). Pregnant women calling the Motherisk Helpline regarding common discomforts report that providers trivialize discomforts when attempting to normalize (Madjunkova, Maltepe, & Koren, 2013). A woman is likely to feel less stress when she understands the physiologic basis of her symptoms, knows when she may be reassured of the well-being of her baby, and knows when to seek additional medical evaluation. Knowledge regarding self-care measures to prevent and relieve discomforts may increase her sense of autonomy and control. It is therefore a primary responsibility of the healthcare provider to provide anticipatory guidance regarding the physiologic basis and treatment of common discomforts of pregnancy. Women with multiple or severe symptoms must be screened for depression and anxiety, as these can each increase symp-toms, and conversely, multiple symptoms may increase the risk of developing depression (Kamysheva, Wertheim, Skouteris, Paxton, & Milgrom, 2009). Poor quality of sleep may also contribute to the develop-ment of physical complaints and depressive symptoms and may be correlated with preterm birth (Strange, Parker, Moore, Strickland, & Bliwise, 2009). Providers can help women pri-oritize adequate sleep and provide education regarding sleep hygiene practices. Poor sleep is a common discomfort of preg-nancy (Kizilirmak, Timur, & Kartal, 2012). Cynthia Belew and Jamie Meyerhoff Co MMon D Is Co Mforts of Pregnan C y© Eliks/Shutterstock; © donatas1205/Shutterstock 290 32Chapt Er
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side effects. Antihistamines such as diphenhydramine are Pregnancy Category B and sedating. However, pharma-cologic treatment has been shown in meta-analysis to be no superior to behavioral therapy in treating insomnia (Mitchell et al., 2012). III. Musculoskeletal Hormonal changes of pregnancy cause relaxation of ligaments throughout the body. The resulting increased mobility of pelvic joints and widening of the sacroiliac and symphyseal joints facilitate childbirth but may lead to pelvic instability and pain. Biomechanical factors also contribute to pregnancy dis-comforts. The growing uterus moves the center of gravity for-ward, pulls the spine into lordosis, and strains the lower back. In most cases pain resolves within 4 weeks after delivery. Two types of lumbopelvic pain are common during preg-nancy. Low back pain (LBP) is musculoskeletal pain experi-enced in the area of the lumbar spine. Pelvic girdle pain (PGP) is musculoskeletal pain experienced in the sacroiliac area, the symphysis pubis, or gluteal area, possibly with radiation to the posterior thigh. LBP and PGP may occur concurrently (Vermani, Mittal, & Weeks, 2009). Both LBP and PGP may be provoked by any sustained posture or activity, including prolonged sitting, standing, or walking. PGP generally is more debilitating than LBP (Gutke, Oberg, & Ostgaard, 2006). Women with PGP may report a “catching” sensation in the leg while walking and may report that pain is aggravated by twist-ing, standing on one leg, climbing stairs, and turning in bed. Many treatments target both LBP and PGP; differences in approach are specified next and in T able 32-1. A. Prevention The woman with strong abdominal, back, gluteal, and pelvic muscles may be less likely to develop lumbopelvic pain of pregnancy (Bewyer, Bewyer, & Messenger, 2009). Several studies show that physical fitness exercises before pregnancy may reduce a woman's risk of developing back pain in pregnancy (Vermani et al., 2009). A tailored exer-cise program during pregnancy was shown to be effective in preventing LBP (Mørkved, Salvesen, Schei, Lydersen, & Bø, 2007). Individualized exercise programs are generally more effective than group training or no treatment. Workplace restrictions may significantly affect a wom-an's risk. Because sustained sitting, standing, or walking may provoke pain, a pregnant woman benefits from the freedom to change activities and positions frequently. Research shows that pregnant women who have job autonomy and the ability to take breaks at work experience less back pain, whereas those working in jobs that neces-sitate staying in a confined area experience more back pain (Cheng et al., 2009). Creation of an evening rhythm that is performed every night before going to sleep including decreased stimulation before time of sleep may be helpful. A pregnant woman can note factors that help her feel drowsy, safe, and relaxed and be encouraged to systemically implement those every evening. Common things that relax include massage, warm baths and showers, low light, warm environment, strolling outside, calming music or scents, reading children's bed-time stories, singing lullabies, and humor. Chamomile is shown to have effectiveness for anxiety (Amsterdam et al., 2009) and may be helpful for pro-moting sleep. Other safe herbs include linden, valerian, and passionflower. Catnip specifically helps with an overthinking/overactive mind. These herbs can be taken as a tincture, capsule, or tea. The pregnant woman should also note individual factors that activate her. Common things that activate/overstimulate are media—movies, television, web surf-ing; disturbing information, news, charged conversa-tions, topics related to changes, money, or planning; worry. Exposure to screen light from computers, tablets, and cellphones has an impact on circadian rhythms. Control of light/dark exposure patterns can powerfully affect sleep and mood. Evening exposure to blue light, including that from computer, tablet, and cellphone screens, suppresses melatonin production, disrupts sleep quality, and leads to decreased alertness the next morn-ing (Sroykham & Wongsawat, 2013; West et al., 2011). Blocking of late evening blue-light exposure through use of amber-lensed glasses and/or low-blue-light bulbs improves sleep quality and mood (Burkhart & Phelps, 2009). Morning exposure to bright light, either through the use of a light box, blue-light enhanced bulbs, or sun-light, enhances cognitive performance, mood, and well-being (Gabel et al., 2013). Many small studies in a nonpregnant population have shown acupuncture to be a highly effective treatment for insomnia (Lan et al., 2015). In a blinded randomized clinical trial using “double dummy” technique, the acu-puncture cohort slept more and more deeply and also reported significantly better daytime functioning and return of their full energetic state; this concords with Chinese medical theory that “energetic daytime function” and “powerful nocturnal sleep” form a circle. Rupture of this cycle leads to “daytime low spirit” and “nighttime hyperarousal state” (Guo, Wang, Liu, Yi, & Cheng, 2013). In this trial, acupuncture was administered for 30 minutes three times a week. An increasing number of communities have the availability of low-cost acupuncture treatment through community acupuncture clinics (https://www . pocacoop. com). Pharmacologic treatment of insomnia is discouraged for use in pregnancy due to inadequate safety data and 291 Musculoskeletal
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B. Database (may include but is not limited to) The distribution of pain is the most useful history item for  diagnosis. The presence of “red flag” signs and symptoms indicates the possibility of disk herniation and requires immediate consultation and possibly magnetic resonance imaging of the spine (T able 32-2). 1. S ubjective a. S igns or symptoms of preterm labor b. S igns or symptoms of pyelonephritis c. E vents preceding onset i. R ecent or past history of physical trauma ii. H istory of similar pain iii. A nxiety or depression iv. P atterns of activity throughout the day d. L ocation and characteristics of pain i. R adiation: bilateral or unilateral to thigh or foot ii. P attern of pain: intermittent or constant iii. P ostures or movements that provoke or alleviate pain iv. Qual ity: sharp, aching, dull; intensityv. L evel of impact on function and patterns of pacing activity during the day vi. S elf-treatment, coping strategies, pain beliefs, remedies, and over-the-counter medications Table 32-1 Dif ferential Diagnosis and Management of Pelvic Pain and Low Back Pain in Pregnancy subjective Physical e xam Imaging tr eatment Low back pain Lumbar pain, worse with forward flexion Negative posterior pelvic pain provocation test Not indicated Water aerobics Group exercise for abdominal, back, and pelvic strength Acupuncture Osteopathic manipulation Exercise: pelvic tilt Abdominal support garments Pelvic girdle pain Sacroiliac pain May radiate to posterior thigh May involve symphysis pubis or gluteal area Positive posterior pelvic pain provocation test Not indicated Nonelastic pelvic belt to increase stability of sacroiliac joint Individualized pelvic stabilizing and core strengthening exercises Cauda equina syndrome (severe nerve compression)Rapid onset of bilateral radiating pain Lower extremity numbness and weakness Numbness of perineum, inner thigh, back of legs Bladder or bowel dysfunction Supine straight leg raise elicits radiating pain to ipsilateral foot on flexion of hip Immediate MRI Orthopedic consultation If stable: bed rest and muscle relaxants If deteriorating: surgery Data from Smith, M. W., Marcus, P. S., & Wurtz, L. D. (2008). Orthopedic issues in pregnancy. Obstetrical & Gynecological Survey, 63(2), 103-111; Vermani, E., Mittal, R., & Weeks, A. (2009). Pelvic girdle pain and low back pain in pregnancy: A review. Pain Practice, 10(1), 60-71. Table 32-2 Musculoskeletal Red Flag Symptoms Requiring Consultation or Referral Sudden onset of incapacitating back or leg pain, especially pain radiating from the spine along a dermatome bilaterally Numbness of perineum, inner thighs, or backs of legs Bladder or bowel dysfunction, decreased rectal sphincter tone Localized neurologic symptoms (symptoms limited to one nerve root dermatome) Decreased muscle strength and sensitivity Structural deformity Altered deep tendon reflexes Localized neurology (symptoms limited to one nerve root dermatome)292 CHAPTER 32 | Common Discomforts of Pregnancy
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2. Obj ective a. Di gital cervical examination to rule out preterm labor if indicated (see Chapter 35 on preterm birth management) b. T est for costovertebral angle tenderness to rule out pyelonephritis c. Obs erve gait and ability to change positions; observe distress level d. P alpate over the sacroiliac, lumbar, symphysis, and gluteal regions (may help to identify pain distribution to differentiate between LBP and PGP; may also rule out structural abnormalities) e. D o a posterior pelvic pain provocation test to differentiate PGP from LBPi. The p atient lies supine with hips flexed to 90 degrees. ii. The ex aminer applies pressure on the flexed knee in the longitudinal axis of the femur while stabilizing the pelvis with the other hand resting on the opposite anterior supe-rior iliac spine. iii. I f this maneuver produces deep pain in the gluteal region, the test is positive and sup-ports a diagnosis of PGP. f. P erform the supine active straight leg raise (SLR) test to identify the possibility of disk herniation with nerve compression. If the SLR elicits pain radiating in a dermatomal pattern or if there is numbness or leg weakness, carry out the following tests: reflexes (Achilles or knee), sensation of lateral and medial sides of feet and toes, and strength testing of the big toe during extension. g. I maging studies, such as magnetic resonance imaging, are recommended only when there are multiple red flags (Albert, Ostgaard, Sturesson, Stuge, & Vleeming, 2008). 3. Di fferential diagnosis a. P regnancy-related LBP or PGP b. P reterm labor c. P yelonephritis d. M uscle strain caused by trauma e. S ciatica 4. Go als for clinical management a. E ducate women about physical fitness for pre-vention of musculoskeletal pain b. A ssess musculoskeletal pain in pregnant women, ruling out serious pathology c. P rovide treatment plans, education, and referrals for women with low back pain or pelvic girdle pain during pregnancy5. Management a. M aternity support garments i. F or PGP, a nonelastic pelvic belt stabilizes the sacroiliac joints and may provide pain relief (Damen, Mens, Snijders, & Stam, 2006). It is most effective when at the level of the greater trocanters. ii. P hysiotherapists recommend that it be worn for short periods of time rather than continuously (Albert et al., 2008; Chow et al., 2009). iii. PGP i s less likely than LBP to respond to exercise classes. The abdominal lift garment may be the most beneficial type of mater-nity support garment for LBP (Albert et al., 2008). b. E xercise i. Gr oup exercise focused on increasing strength and flexibility and water exer-cise have been shown to decrease LBP in the second part of pregnancy (Pennick & Liddle, 2013). ii. Ge ntle exercise at home may be helpful, including the pelvic tilt, knee pull, curl-up, lateral SLR, and pelvic floor exercises. iii. F or PGP, pelvic stabilizing exercises given by a physical therapist are effective (Vleeming, Albert, Ostgaard, Sturesson, & Stuge, 2008). c. W orkplace modification: a provider's letter to the employer recommending regular rest breaks and movement outside of confined working areas may be beneficial for some women. d. M edication for pregnancy-related LBP and PGP i. Ac etaminophen may not be more effec-tive than placebo for LBP and PGP of pregnancy (Vermani et al., 2009). ii. N onsteroidal anti-inflammatory drugs are not recommended in the last trimester of pregnancy because of risk of premature closure of the ductus arteriosus and risk of oligohydramnios. iii. O pioids: Occasional use of small doses of opioids (e. g., codeine) is sometimes indicat-ed in severe cases of pain. Opioid use in late pregnancy can cause respiratory depression in the newborn and, with long-term use, withdrawal effects in the newborn (Vermani et al., 2009). 6. R eferrals and self-management resources a. E uropean guidelines consider evidence suf-ficient to recommend the following for PGP: 293 Musculoskeletal
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maternal exposure to drugs, chemicals, diseases, radiation, and environmental agents. They maintain several helplines, includ-ing one dedicated to questions regarding nausea and vomiting of pregnancy (NVP). A. Nausea and vomiting of pregnancy 1. D efinition and clinical implications Nausea and vomiting of pregnancy are considered to be a result of hormonal changes. About 50 to 85% of all pregnant women experience NVP. Typically, symptom onset is around 5-7 weeks from the last menstrual period, with resolution at 11-14 weeks gestation. In a subset of women, symptoms may per-sist until 18 weeks, and 5% of pregnant women have nausea throughout pregnancy. If onset of symptoms occurs at a gestational age of 10 weeks or greater, the etiology is not likely to be pregnancy. NVP is a normal part of most pregnancies. Although NVP may have a significant impact on a woman's daily life, it is benign. The presence of NVP is associated with a lower risk of miscarriage (Weigel et al., 2006). The reduced maternal nutrient intake that commonly occurs during the first trimester in women with NVP seems to cause complex hormonal and metabolic changes that actually enhance placen-tal growth (Huxley, 2000). It is also proposed that NVP serves a protective evolutionary function, caus-ing women to avoid foods that may cause harm to the embryo (Sherman & Flaxman, 2002). Most women make up for first-trimester weight loss by gaining more weight later in pregnancy. In contrast, hyperemesis gravidarum (HG) can pose serious risks and is a more debilitating condi-tion. On the continuum from severe NVP to HG, HG is defined as symptoms that lead to weight loss of more than 5% of prepregnancy body weight, hypo-kalemia, and dehydration or ketonuria. HG may require hospitalization. Holmgrem and colleagues reviewed the management of HG (Holmgren, Aagaard-Tillery, Silver, Porter, & Varner, 2008). HG requires medical management because it can be associated with serious sequelae, such as micronutri-ent deficiency or Wernicke's encephalopathy, if not properly managed (Dodds, Fell, Joseph, Allen, & Butler, 2006). If heartburn exists concurrent with NVP, phar-macologic treatment of the heartburn is shown to decrease symptoms of NVP (Gill, Maltepe, Mastali, & Koren, 2009). exercise, individualized physical therapy, mas-sage, acupuncture, osteopathic manipulation, and chiropractic care (Albert et al., 2008). b. U seful online resources include the Association of Chartered Physiotherapists in Women's Health (www. acpwh. org) and the Pelvic Partnership (http://www. pelvicpartnership. org. uk/). 7. P atient education (adapted from www. acpwh. org) a. T each pertinent anatomy and physiology and reassure that pelvic and back pain are a normal part of pregnancy for many women, likely to resolve in the weeks after birth. b. P rovide guidance regarding appropriate pacing of activity and rest. i. Be as a ctive as possible within the limits of pain. Staying active can reduce pain and improve function (Krismer & van Tulder, 2007). ii. A void fatigue by taking frequent rest breaks. iii. A void being in one posture for a prolonged time. iv. A void activities that worsen pain. Encourage sitting down to put on pants and shoes. c. Adv ise supportive shoes and avoidance of heels. d. R ecommend placement of one pillow between the knees and one under the abdomen when sleeping side-lying IV. g astrointestinal tract Elevated levels of progesterone during pregnancy facilitate maintenance of the pregnancy by relaxing the uterine muscle. However, smooth muscle relaxation decreases gastric and intestinal motility, leading to nausea, dyspepsia, and constipa-tion. Mechanical pressure from the enlarging uterus contrib-utes to heartburn. Management of common gastrointestinal tract discomforts of pregnancy, such as nausea, heartburn, and constipation, proceeds in a stepwise algorithm that begins with lifestyle and dietary modifications and gentle natural remedies. Pharmaceutical treatment is reserved for persistent or severe symptoms. This conservative approach is recom-mended because of the benign nature of common gastrointes-tinal tract discomforts of pregnancy. The Canadian organization Motherisk, a clinical research and teaching program at The Hospital for Sick Children, has an excellent online resource (www. motherisk. org). They pro-vide information both to pregnant and lactating women and to healthcare professionals regarding risks to the fetus from 294 CHAPTER 32 | Common Discomforts of Pregnancy
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B. Database 1. S ubjective data a. T iming of onset, pattern, and frequency of nausea and vomiting i. The “P UQE” (pregnancy-unique quantifi-cation of emesis/nausea) index may be used to evaluate severity. The woman's subjec-tive experience of the impact of symptoms on her life is an important consideration and may override the PUQE score (King & Murphy, 2009) (T able 32-3). b. T riggers and coexisting gastric reflux c. Ea ting habits and self-treatment d. R ed flags for gallbladder disease and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets)i. E pigastric pain, right upper quadrant pain, or coffee grounds emesis ii. U pper abdominal pain in a pattern of biliary colic (episodes of sharp, intense pain after meals or at night lasting 30 minutes to 3 hours, or radiation to back or right shoulder) may indicate gallbladder disease. 2. Obj ective data a. W eight loss b. U rinalysis: ketones and specific gravity c. S igns of dehydration: tachycardia, dry mucosa, and sunken eyes d. I f severe symptoms are present: order an electro-lyte panel and an obstetric ultrasound to rule out twin gestation or trophoblastic disease (molar pregnancy)e. I f onset of symptoms occurs in third trimester: rule out HELLP syndrome with complete blood count (CBC) and platelets even if symptoms are not severe f. I f symptoms suggest gallbladder disease: CBC, lipase, liver enzymes, and abdominal ultrasound 3. Di fferential diagnosis a. D ehydration b. Ke tonuria c. Ele ctrolyte imbalance d. HG e. G allbladder, liver, or pancreatic disease f. H ELLP syndrome (third trimester) g. F atty liver of pregnancy (rare) 4. Go als for clinical management a. Di fferentiate normal nausea and vomiting of pregnancy (NVP) from hyperemesis and other serious pathology. b. P rovide comprehensive education for women with NVP about dietary and lifestyle changes to minimize symptoms. c. P rovide evidence-based information about safe alternative and complementary treatments for NVP. d. P rovide evidence-based pharmacotherapy for treatment of NVP. e. A ssess results of treatment and provide intrave-nous rehydration as needed. 5. T reatment Women commonly find that one therapeutic mea-sure works well for a few days but then becomes less Table 32-3 Pregnancy-Unique Quantification of Emesis and Nausea Index 1. On an average day, for how long do you feel nauseated or sick to your stomach? > 6 hr 4-6 hr 2-3 hr ≤ 1 hr Not at all (5 points) (4 points) (3 points) (2 points) (1 point) 2. On an average day, how many times do you vomit or throw up? ≥ 7 5-6 3-4 1-2 None (5 points) (4 points) (3 points) (2 points) (1 point) 3. On an average day, how many times do you have retching or dry heaves without bringing anything up? ≥ 7 5-6 3-4 1-2 None (5 points) (4 points) (3 points) (2 points) (1 point) Total score (sum of replies to 1, 2, and 3): mild NVP, ≤ 6; moderate NVP, 7-12; severe NVP, ≥ 13. Reprinted from Lacasse, A., Rey, E., Ferreira, E., Morin, C., & Bérard, A. (2008). Validity of a modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scoring index to assess severity of nausea and vomiting of pregnancy. American Journal of Obstetrics and Gynecology, 198(1), 71. e3; with permission from Elsevier. 295 Gastrointestinal tract
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b. E vidence exists supporting the effectiveness and safety of the following therapies: i. Ac upressure wrist bands (Seabands, T ravel-Eze) worn continuously over the P6 acupunc-ture point (Can Gürkan & Arslan, 2008). ii. G inger capsules, 250 mg orally four times a day (Bryer, 2005) iii. V itamin B6, 25 mg orally three times a day. Avoid excessive doses, which may cause peripheral neuropathy (Keller, Frederking, & Layer, 2008). c. I ntravenous fluid therapy: Intravenous fluid therapy with normal saline, alone or in combi-nation with pharmaceuticals, typically causes an improvement of symptoms for several days. Some women choose it as a primary manage-ment strategy, receiving hydration every few days as needed (King & Murphy, 2009). Avoid dextrose-containing fluids, because they may precipitate Wernicke's encephalopathy, a rare but serious complication, in a woman with thia-mine deficiency. The addition of thiamine is recommended for the prevention of Wernicke's encephalopathy. Potassium chloride may be added as needed. Consultation is necessary for persistent nausea and vomiting with dehydra-tion, and intravenous vitamins and minerals may be required. 10. Pha rmacotherapy (see T able 32-4) a. A ntihistamines Diclegis, delayed release (doxylamine 10 mg, combined with pyridoxine 10 mg) is the only drug approved by the Food and Drug Administration (FDA) for nausea and vomit-ing during pregnancy. A large body of evidence supports both the safety and effectiveness of the combination. Y ears of widespread use of this medication in Canada and in the United States in the 1980s contribute to its high safety profile (Nuangchamnong & Niebyl, 2014). Diclegis is taken as a daily prescription, rather than as needed. b. D opamine antagonists Metoclopramide has been a drug of choice for many providers in treating severe NVP and HG. Recent research examining more than 3,400 first-trimester exposures found no association with any of several adverse outcomes (Matok et al., 2009). In a comparison of prometha-zine and metoclopramide, T an and colleagues found similar efficacy but metoclopramide had fewer side effects (T an, Khine, Vallikkannu,  & Omar, 2010). In a small study on treatment effective. Knowledge about multiple treatments is beneficial to switch tactics as needed. 6. E ducation Reassure that mild to moderate symptoms do not have a negative effect on fetal growth and develop-ment. Discuss dietary and lifestyle changes. 7. Hydration and nutrition a. Avoid dehydration by sipping small amounts of water frequently (as little as an ounce every 15  minutes). Large volumes of fluid may pro-voke nausea. b. Dr ink cold fluids between meals instead of with meals. c. Ea t small amounts of food that include protein every 1-2 hours. Low blood sugar provokes nausea. Eat a high-protein snack at bedtime. d. Ke ep dry crackers at the bedside and eat a few before rising in the morning. e. A void spicy or fatty foods. 8. T rigger avoidance: triggers are highly individual but may include a. S trong odors, stuffy rooms, or bus travel. b. The sight or smell of certain foods. c. B rushing teeth. Avoid brushing teeth within 1-2  hours after eating. Use a child's size tooth-brush and small amounts of a low-foaming tooth-paste or brush without toothpaste. d. M ultivitamins: continue to take multivitamin if possible, because it may decrease symptoms, but if taking multivitamin aggravates nausea, discontinue and replace with 600 mcg of folic acid. Resume multivitamin at a later gestational age when NVP resolves. A multivitamin without iron may be more easily tolerated. 9. The rapeutic a. A lternative and complementary i. The C anadian Motherisk reports that 61% of women with NVP report use of comple-mentary and alternative remedies but only 8% of women had discussed these remedies with their healthcare provider (Hollyer, Boon, Georgousis, Smith, & Einarson, 2002) ii. G inger, chamomile, fennel seed, raspberry leaf, and mint are all used traditionally in a tea or tincture for gastric upset. These herbs are regarded as safe by the Canadian Motherisk group (Mills, Duguoa, Perri, & Koren, 2006) and the German Commission E (Blumenthal, Goldberg, & Brinckmann, 2000). Both are authoritative expert panels dealing with the topic of herb safety. 296 CHAPTER 32 | Common Discomforts of Pregnancy
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d. 5-Hydroxytryptamine 3-receptor antagonists Ondansetron has been used increasingly in treat-ment of NVP. However, two large studies have recently found statistically significant increases in fetal cardiac anomalies associated with use of ondansetron in the first trimester (Danielsson, Wikner, & Källén, 2014). Ondansetron should not be used during the first trimester. The FDA has issued warnings about serious maternal dys-rhythmias associated with use of ondansetron (Koren, 2014). Additionally, there have been 33 case reports of rare but life-threatening intes-tinal obstruction in which ondansetron was the sole associated pharmaceutical, one of which was in a pregnant patient (Cohen et al, 2014). of hyperemesis gravidarum, metoclopramide had similar efficacy with increased side effects compared to ondansetron (Abas, T an, Azmi, & Omar, 2014). Metoclopramide was associated with increased dizziness, dry mouth, headache, diarrhea, and palpitations. Despite these side effects, it remains a reasonable treatment choice. c. P henothiazines Promethazine and prochlorpemazine may be as effective as ondansetron and have no evidence of being teratogenic, although there is less human data than for metoclopramide and Diclegis (Briggs, Freeman, & Yaffe, 2015). These drugs cause significant sedation, making them difficult for women to tolerate. Table 32-4 Pharmacotherapy for NVP generic name (trade name) Dosage Major s ide e ffects Antihistamines Doxylamine succinate-pyroxidine hydrochloride (Diclegis®)10 mg doxylamine combined with 10 mg of pyridoxine, delayed release 4 tablets daily: 2 at night, 1 in the morning, 1 in the afternoon Mild drowsiness Diphenhydramine 50-100 mg q 4-6 hr PO/IM/IV For treatment of dystonic reaction: 50 mg IVDrowsiness Trimethobenzamide 200 mg IM/PR q 6-8 hr Drowsiness Dopamine antagonists Metoclopramide 1-2 mg/kg IV (dilute in 50 m L IVF) or 5-10 mg q 8 hr PO/PR/IMAgitation, anxiety, acute dystonic reactions* Prochlorperazine 5-10 mg PO/IV/IM q 6-8 hr or 25 mg rectal suppository BID/prn for breakthrough vomiting with other medications Sedation, anticholinergic effects, EPS Promethazine 12. 5-25 mg PO/IV/IM/PR q 4-6 hr Sedation, anticholinergic effects, dystonic reactions* Serotonin (5-HT3) antagonists Ondansetron Publisher note 4-8 mg PO q 6-8 hr 4-8 mg IV q 12 hr, given over 15 min Headache. Do not use during the first trimester Other Pyridoxine (vitamin B 6) 25 mg TID. Consider combining with doxylamine Zingiber officinale (ginger) Capsules: 250-500 mg TID-QID Not to exceed 1. 5 g in 24 hr * Give 50 mg diphenhydramine before dose to prevent extrapyramidal reactions Modified from King, T. L., & Murphy, P. A. (2009). Evidence-based approaches to managing nausea and vomiting in early pregnancy. Journal of Midwifery & Women's Health, 54(6), 435; with permission from Elsevier. 297 Gastrointestinal tract
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11. F ollow-up a. S end to labor and delivery for rehydration and medication as needed. b. C onsider increasing the frequency of prenatal visits to once or twice weekly until symptoms diminish. c. A ssessing and T reating Women with Nausea in Pregnancy. V. Heartburn A. Definition Heartburn, also known as gastroesophageal reflux disease, is a normal part of most pregnancies. Symptoms are usu-ally mild to moderate. Lifestyle and dietary modifications accompanied by safe home remedies and simple antacids often are effective in providing relief. Pregnancy seems to be protective against esophagitis and gastric ulcer disease, and these conditions are uncommon during pregnancy (Cappell, 2003). Even severe symptoms of gastroesopha-geal reflux disease usually resolve soon after birth. B. Database (may include but is not limited to) Red flag symptoms and signs (listed next in section 1b) help in the differentiation of benign heartburn from more serious medical conditions. Gallbladder disease, pancre-atitis, and, in the third trimester, HELLP syndrome must be ruled out. Red flag symptoms and signs require imme-diate consultation. 1. S ubjective a. T ypical symptoms of gastric acid reflux during pregnancy include i. B urning in the upper abdomen or midchest. ii. Di scomfort associated with eating or with a recumbent position. iii. T ypically worsens as the pregnancy progresses. iv. R elieved by antacids. b. R ed flag symptoms of include: i. G allbladder disease: episodes of biliary colic ii. H ELLP: Right upper quadrant, mide-pigastrium, or retrosternal pain, nausea, vomiting, and malaise. HELLP may occur without hypertension. iii. P ancreatitis: acute onset of persistent, severe epigastric pain. 2. Obj ective a. P hysical examination i. A ssess for red flag signs of HELLP ii. R ight upper quadrant or midepigastrium tendernessb. L aboratory tests i. S erum amylase and lipase as indicated to rule out pancreatitis ii. L iver enzymes as indicated to rule out liver disease iii. L iver enzymes and platelets as indicated to rule out HELLP 3. A ssessment a. N ormal gastric reflux of pregnancy. This diagno-sis is based on symptoms alone. b. R ule out liver disease, gallbladder disease, and, if in third trimester, HELLP 4. Go als of clinical management a. A ssess reflux during pregnancy and rule out serious pathology. b. S elect pharmaceutical treatments for reflux that have the minimum adverse effects. c. E ducate women about the adverse effects of proton pump inhibitors and H2 agonists. d. E ducate women about lifestyle and dietary modifications to minimize symptoms of reflux during pregnancy. 5. M anagement (see T able 32-5) Stomach acid is necessary for absorption of essen-tial nutrients, destruction of ingested pathogens, and maintenance of a beneficial gastrointestinal micro-biome, all key functions for maintenance of optimal health. Suppression of stomach acid, especially the profound and long-lasting suppression of proton pump inhibitors (PPIs), is linked with a number of adverse effects. A stepwise approach to gastroesopha-geal reflux disease (GERD) is advised, starting with lifestyle and dietary modifications, moving to raft-forming or simple antacids and then to sucralfate, reserving histamine-2 receptor antagonists (H2RA) and PPIs for persistent severe symptoms. Adverse effects of H2RAs and PPIs are addressed later. The detrimental effects of PPIs may not be seen with ant-acids because antacids affect gastric acidity to a lesser degree and for a shorter duration of time. Rebound acid hypersecretion occurs after use of PPIs but not after use of H2RAs (Waldum, Qvigstad, Fossmark, Kleveland, & Sandvik, 2010). Expert opinion and traditional use support the benefit and safety of marshmallow root (Althea) and the inner bark of slippery elm (Ulmas rubra) for heartburn and gastritis (Romm, 2010). They contain mucilage (insoluble polysaccharides), which absorbs acid and sooths irritated or inflamed mucosa (Deters et al., 2010). Raft-forming antireflux medications (Gaviscon) combine a low dose of antacid (magnesium and alu-minum salts) with alginic acid and may be more 298 CHAPTER 32 | Common Discomforts of Pregnancy
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Table 32-5 Management for Heartburn During Pregnancy Lifestyle Modifications Eat small frequent meals rather than two large meals (Jarosz & Taraszewska, 2014) Avoid frequent consumption of mint tea (Jarosz & Taraszewska, 2014) Do not drink large amounts of liquid with meals Take a walk after dinner (Karim et al., 2011) Do not recline after meals (Karim et al., 2011) Do not gain more than the recommended weight during pregnancy Eat in a slow and relaxed manner (Yamamichi et al., 2012) Identify and avoid triggers, which may include carbohydrates (Austin, Thiny, Westman, Yancy, & Shaheen, 2006), tobacco, alcohol, and chocolate (Kaltenbach, Crockett, & Gerson, 2006) Remedies ( r omm, 2010) Raw almonds (8-10 at a time) chewed slowly, as frequently as needed Slippery elm lozenges 2-4 PRN, or slippery elm powder (one teaspoon stirred into applesauce, juice, or water) Marshmallow root: one ounce of dried herb steeped for at least 30 minutes in one quart of hot water, strain, sip throughout the day as needed, up to three cups daily. Strong tea of chamomile, fennel, ginger, linden, alone or in combination. Dandelion root tea (one to three cups sipped throughout the day) or tincture (20-40 drops diluted in a small amount of water three times daily); contraindicated if there are painful gallstones (acute biliary colic) or cholecystitis. Antacids Avoid sodium bicarbonate, bismuth, Alka Seltzer (Mahadevan & Kane, 2006)Medication Considerations Gaviscon (Quartarone, 2013) Avoid high doses in pregnancy Generally well tolerated For maximum effect, take 30 minutes after meals and maintain upright position. Calcium-or magnesium-containing antacids (Tytgat et al., 2003) Excessive use of calcium carbonate (> 2 g/day) can result in milk alkali syndrome (hypercalcemia and alkalosis, which can cause renal damage). Magnesium-containing antacids may cause diarrhea. Avoid excessive doses of aluminum salts. Although some advocate the benefits of calcium carbonate as an antacid because it also provides supplemental calcium, in reality calcium carbonate contains only 40% elemental calcium and has poor bioavailability (Sipponen & Härkönen, 2010). Sucralfate Adverse effects unlikely Histamine-2 receptor antagonists (H2RA) Cimetidine or ranitidine are preferred (Mahadevan & Kane, 2006). A decrease in effectiveness to H2RA treatment may occur within 2-6 weeks of initiation of therapy (Komazawa et al., 2003). The safety of H2RAs during the first trimester has not been established (Gilboa, Ailes, Rai, Anderson, & Honein, 2014). Proton Pump Inhibitors Omeprazole (Prilosec®) is recommended as the PPI of choice (Mahadevan & Kane, 2006). The use of PPIs during pregnancy is not associated with an increased risk of birth defects, perinatal mortality, or morbidity (Matok et al., 2012). Adverse effects include impaired micronutrient absorption, increased risk of enteric infections including gastroenteritis and Clostridium difficile infection, increased risk of community-acquired pneumonia, disrupted gastrointestinal microbiome, and an association with increased risk of allergic disease in the offspring (see text). 299 Heartburn
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effective than antacids alone (De Ruigh, Roman, Chen, Pandolfino, & Kahrilas, 2014; Rohof, Bennink, Smout, Thomas, & Boeckxstaens, 2014). Alginate forms a viscous foam that floats on the surface of the gastric pool, providing a mechanical barrier to reflux. If reflux occurs the nonacidic foam rather than the acidic stomach content moves into the esophagus. Research has demonstrated alginate-containing ant-acids to be highly effective and safe during pregnancy (Quartarone, 2013). a. Adv erse effects of acid inhibitors: i. M icronutrient absorption A dramatic decrease in absorption of vitamin B 12 is seen after only 2 weeks of treatment with a PPI (Marcuard, Albernaz,  & Khazanie, 1994), and use of both H2RA and PPI is significantly associ-ated with the presence of vitamin B 12 defi-ciency (Lam, Schneider, Zhao, & Corley, 2014). The FDA has issued warnings regarding the correlation of PPI use with hypomagnesemia (FDA, 2011; Markovits et al., 2014). PPIs are also linked with hypocalcemia and hypokalemia (Luk, Parsons, Lee, & Hughes, 2013). The impli-cations of PPI-induced hypomagnesemia and hypocalcemia and low B 12 levels during pregnancy have not been explored. Adequate magnesium and calcium levels are important for normal fetal bone devel-opment, and the link between low calcium intake and risk of gestational hyperten-sion is well described (Dodd, O'Brien, & Grivel, 2014). The theoretical link between PPI use and increased risk of calcium-deficiency disorders such as preeclampsia has not been investigated. ii. R isk of infection PPI use is associated with increased sus-ceptibility of food-borne and enteric infec-tion including Salmonella, invasive strains of Escherichia coli, Listeria, and Clostridium difficile infection (CDI) (Bavishi & Dupont, 2011). Outpatients prescribed PPIs have as much as a threefold increased risk of CDI compared with matched controls (Freedberg, Lebwohl, & Abrams, 2014). The FDA has issued a drug alert regarding the connection of PPI use with CDI (FDA, 2012) and has recommended that PPIs be prescribed at the lowest dose and shortest duration possible. iii. A lternations in the microbiome Use of acid-suppressing drugs rapidly alters the microbiome in the stomach, esophagus, and small intestine, shifting the popula-tion toward inflammatory flora (Freedburg et al., 2014) and causing small intestinal bacterial overgrowth (Del Piano et al., 2014). Researchers are exploring the role of selected probiotic supplements to negate the harmful effect of PPIs on the microbiome (Del Piano et al., 2014). The disruption in microbiome might explain the association of prenatal use of acid-suppressive drugs with an increased risk of allergic disease in the offspring (Mulder et al., 2014). 6. F ollow-up a. I ncrease frequency of visits based on response to treatment b. N utritionist referral c. P hysician consultation for persistent severe symptoms unresponsive to treatment referen Ces Abas, M. N., T an, P. C., Azmi, N., et al. (2014). Ondansetron compared with metoclopramide for hyperemesis gravidarum: A randomized controlled trial. Obstetrics and Gynecology, 123(6), 1272-1279. Albert, H. B., Ostgaard, H. C., Sturesson, B., Stuge, B., & Vleeming, A. (2008). European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), 794-819. Austin, G. L., Thiny, M. T., Westman,. E C., Yancy, W. S. Jr., & Shaheen, N. J. (2006). A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms. Digestive Diseases and Sciences, 51(8), 1307-1312. Avery, M. D., Saftner, M. A., Larson, B., & Weinfurter, E. V. (2014). A  systematic review of maternal confidence for physiologic birth: Characteristics of prenatal care and confidence measurement. Journal of Midwifery & Women's Health, 59(6), 586-595. Bavishi, C., & Dupont, H. L. (2011). Systematic review: The use of proton pump inhibitors and increased susceptibility to enteric infection. Alimentary Pharmacology & Therapeutics, 34(11-12), 1269-1281. Bewyer, K. J., Bewyer, D. C., & Messenger, D. (2009). Pilot data: Association between gluteus medius weakness and low back pain during pregnancy. Iowa Orthopaedic Journal, 29, 97-99. Blumenthal, M., Goldberg, A., & Brinckmann, J. (2000). Herbal medicine: Expanded Commission E monographs. Newton, MA: Integrative Medicine Communications. Briggs, G. G., Freeman, R. K., & Yaffe, S. J. (2015). Drugs in pregnancy and lactation: A reference guide to fetal and neonatal risk (10th ed. ). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health. Bryer, E. (2005). A literature review of the effectiveness of ginger in allevi-ating mild-to-moderate nausea and vomiting of pregnancy. Journal of Midwifery & Women's Health, 50(1), e1-e3. Burkhart, K., & Phelps, J. R. (2009). Amber lenses to block blue light and improve sleep: A randomized trial. Chronobiology International, 26(8), 1602-1612. 300 CHAPTER 32 | Common Discomforts of Pregnancy
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Can Gürkan, O., & Arslan, H. (2008). Effect of acupressure on nausea and vomiting during pregnancy. Complementary Therapy Clinical Practice, 14(1), 46-52. Cappell, M. S. (2003). Gastric and duodenal ulcers during pregnancy. Gastroenterology Clinics of North America, 32(1), 263-308. Cheng, P. L., Pantel, M., Smith, J. T., Dumas, G. A., Leger, A. B., Plamondon, A., et al. (2009). Back pain of working pregnant women: Identification of associated occupational factors. Applied Ergonomics, 40(3), 419-423. Chow, D. H., Chung, J. W., Ho, S., Lao, T., Li, Y., & Yu, W. (2009). Effectiveness of maternity support belts in reducing low back pain during pregnancy: A review. Journal of Clinical Nursing, 18(11), 1523-1532. Cohen, R., Shlomo, M., Dil, D. N., Dinavitser, N., Berkovitch, M., & Koren, G. (2014). Intestinal obstruction in pregnancy by ondansetron. Reproductive T oxicology, 50, 152-153. Damen, L., Mens, J. M., Snijders, C. J., & Stam, H. J. (2006). The mechanical effect of a pelvic belt in patients with pregnancy-related pelvic pain. Clinical Biomechanics, 21(2), 122-127. Danielsson, B., Wikner, B. N., & Källén, B. (2014). Use of ondansetron during pregnancy and congenital malformations in the infant. Reproductive T oxicology, 50, 134-137. De Ruigh, A., Roman, S., Chen, J., Pandolfino, E., & Kahrilas, P. J. (2014). Gaviscon Double Action Liquid (antacid & alginate) is more effective than antacid in controlling post-prandial oesophageal acid exposure in GERD patients: A double-blind crossover study. Alimentary Pharmacology & Therapeutics, 40(5), 531-537. Dehlink, E., Y en, E., Leichtner, A. M., Hait, E. J., & Fiebiger, E. (2009). First evidence of a possible association between gastric acid suppression during pregnancy and childhood asthma: A population-based register study. Clinical and Experimental Allergy, 39(2), 246-253. Del Piano, M., Pagliarulo, M., T ari, R., Carmagnola, S., Balzarini, M., Lorenzini, P., et al. (2014). Correlation between chronic treatment with proton pump inhibitors and bacterial overgrowth in the stomach: Any possible beneficial role for selected lactobacilli? Journal of Clinical Gastroenterology, 48(Suppl. 1), S40-S46. Deters, A., Zippel, J., Hellenbrand, N., Pappai, D., Possemeyer, C., & Hensel, A. (2010). Aqueous extracts and polysaccharides from marshmallow roots (Althea officinalis L. ): Cellular internalisation and stimulation of cell physiology of human epithelial cells in vitro. Journal of Ethnopharmacology, 127(1), 62-69. Dodd, J. M., O'Brien, C., & Grivell, R. M. (2014). Preventing pre-eclampsia—Are dietary factors the key? BMC Medicine, 12, 176. doi:10. 1186/s12916-014-0176-4. Dodds, L., Fell, D. B., Joseph, K. S., Allen, V. M., & Butler, B. (2006). Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstetrics & Gynecology, 107(2), 285-292. Food and Drug Administration. (2011). FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs). Retrieved from http://www. fda. gov /Drugs/Drug Safety/ucm245011. htm. Food and Drug Administration. (2012). FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs). Retrieved from http://www. fda. gov/drugs/drugsafety/ucm290510. htm. Freedberg, D. E., Lebwohl, B., & Abrams, J. A. (2014). The impact of proton pump inhibitors on the human gastrointestinal microbiome. Clinics in Laboratory Medicine, 34(4), 771-785. Gabel, V., Maire, M., Reichert, C. F., Chellappa, S. L., Schmidt, C., Hommes, V., et al. (2013). Effects of artificial dawn and morning blue light on daytime cognitive performance, well-being, cortisol and melatonin levels. Chronobiology International, 30(8), 988-997. Gilboa, S. M., Ailes, E. C., Rai, R. P., Anderson, J. A., & Honein, M. A. (2014). Antihistamines and birth defects: A systematic review of the literature. Expert Opinion on Drug Safety, 13(12), 1667-1698. Gill, S. K., Maltepe, C., Mastali, K., & Koren, G. (2009). The effect of acid-reducing pharmacotherapy on the severity of nausea and vomiting of pregnancy. Obstetrics and Gynecology International, Epub July 1, 2009, 585269, 1-4. Guo, J., Wang, L. P., Liu, C. Z., Zhang, J., Wang, G. L., Yi, J. H., et al. (2013). Efficacy of acupuncture for primary insomnia: A randomized controlled clinical trial. Evidence-Based Complementary and Alternative Medicine, 2013, 163850. Gutke, A., Oberg, B., & Ostgaard, H. C. (2006). Pelvic girdle pain and lumbar pain in pregnancy: A cohort study of the consequences in terms of health and functioning. Spine, 31(5), e149-e155. Hollyer, T., Boon, H., Georgousis, A., Smith, M., & Einarson, A. (2002, May 17). The use of CAM by women suffering from nausea and vomiting during pregnancy. BMC Complementary and Alternative Medicine, 2, 5. Holmgren, C., Aagaard-Tillery, K. M., Silver, R. M., Porter, T. F., & Varner, M. (2008). Hyperemesis in pregnancy: An evaluation of treatment strategies with maternal and neonatal outcomes. American Journal of Obstetrics and Gynecology, 198(1), 56. e1-e4. Huxley, R. (2000). Nausea and vomiting in early pregnancy—Its role in placental development. Obstetrics & Gynecology, 95(5), 779-782. Jarosz, M., & T araszewska, A. (2014). Risk factors for gastroesophageal reflux disease: The role of diet. Przeglad Gastroenterologiczny, 9(5), 297-301. Kaltenbach, T., Crockett, S., & Gerson, L. B. (2006). Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach. Archives of Internal Medicine, 166(9), 965-971. Kamysheva, E., Wertheim, E. H., Skouteris, H., Paxton, S. J., & Milgrom, J. (2009). Frequency, severity, and effect on life of physical symptoms experienced during pregnancy. Journal of Midwifery & Women's Health, 54(1), 43-49. Karim, S., Faryal, A., Majid, S., Majid, S., Salih, M., Jafri, F., et al. (2011). Regular post dinner walk; can be a useful lifestyle modification for gastroesophageal reflux. Journal of the Pakistan Medical Association, 61(6), 526-530. Keller, J., Frederking, D., & Layer, P. (2008). The spectrum and treatment of gastrointestinal disorders during pregnancy. Nature Clinical Practice Gastroenterology & Hepatology, 5(8), 430-443. King, T. L., & Murphy, P. A. (2009). Evidence-based approaches to man-aging nausea and vomiting in early pregnancy. Journal of Midwifery & Women's Health, 54(6), 430-444. King, A. C., Oman, R. F., Brassington, G. S., Bliwise, D. L., & Haskell, W. L. (1997). Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. JAMA, 277(1), 32-37. Kizilirmak, A., Timur, S., & Kartal, B. (2012). Insomnia in pregnancy and factors related to insomnia. Scientific World Journal, 2012, 197093. Komazawa, Y., Adachi, K., Mihara, T., Ono, M., Kawamura, A., Fujishiro, H., et al. (2003). T olerance to famotidine and ranitidine treatment after 14 days of administration in healthy subjects without Helicobacter pylori infection. Journal of Gastroenterology and Hepatology, 18(6), 678-682. 301 References
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Mulder, B., Schuiling-Veninga, C. C., Bos, H. J., De Vries, T. W., Jick, S. S., & Hak, E. (2014). Prenatal exposure to acid-suppressive drugs and the risk of allergic diseases in the offspring: A cohort study. Clinical and Experimental Allergy, 44(2), 261-269. Nuangchamnong, N., & Niebyl, J. (2014). Doxylamine succinate-pyridoxine hydrochloride (Diclegis) for the management of nausea and vomiting in pregnancy: An overview. International Journal of Women's Health, 6, 401-409. Pennick, V., & Liddle, S. D. (2013). Interventions for preventing and treat-ing pelvic and back pain in pregnancy. Cochrane Database of Systematic Reviews, 8, CD001139. Quartarone, G. (2013). Gastroesophageal reflux in pregnancy: A systematic review on the benefit of raft forming agents. Minerva Ginecologica, 65(5), 541-549. Rohof, W. O., Bennink, R. J., Smout, A. J., Thomas, E., & Boeckxstaens, G. E. (2013). An alginate-antacid formulation localizes to the acid pocket to reduce acid reflux in patients with gastroesophageal reflux disease. Clinical Gastroenterology and Hepatology, 11(12), 1585-1591; quiz e90. Romm, A. (2010). Botanical medicine for women's health. St. Louis, MO: Churchill Livingstone Elsevier. Sherman, P. W., & Flaxman, S. M. (2002). Nausea and vomiting of pregnancy in an evolutionary perspective. American Journal of Obstetrics and Gynecology, 186(Suppl. 5), S190-S197. Sipponen, P., & Härkönen, M. (2010). Hypochlorhydric stomach: A risk condition for calcium malabsorption and osteoporosis. Scandinavian Journal of Gastroenterology, 45(2), 133-138. Smith, M. W., Marcus, P. S., & Wurtz, L. D. (2008). Orthopedic issues in pregnancy. Obstetrical & Gynecological Survey, 63(2), 103-111. Smith, M. T., Perlis, M. L., Park, A., Smith, M. S., Pennington, J., Giles, D. E., et al. (2002). Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry, 159(1), 5-11. Sroykham, W., & Wongsawat, Y. (2013). Effects of LED-backlit computer screen and emotional selfregulation on human melatonin production. IEEE Engineering in Medicine and Biology Society Conference Proceedings, 2013, 1704-1707. Strange, L. B., Parker, K. P., Moore, M. L., Strickland, O. L., & Bliwise, D. L. (2009). Disturbed sleep and preterm birth: A potential relationship? Clinical and Experimental Obstetrics & Gynecology, 36(3), 166-168. T an, P. C., Khine, P. P., Vallikkannu, N., & Omar, S. Z. (2010). Promethazine compared with metoclopramide for hyperemesis gravidarum: A randomized controlled trial. Obstetrics and Gynecology, 115(5), 975-981. Tytgat, G. N., Heading, R. C., Müller-Lissner, S., Kamm, M. A., Schölmerich, J., Berstad, A., et al. (2003). Contemporary understanding and manage-ment of reflux and constipation in the general population and pregnancy: A consensus meeting. Alimentary Pharmacology & Therapeutics, 18(3), 291-301. Untersmayr, E., & Jensen-Jarolim, E. (2008). The role of protein digestibil-ity and antacids on food allergy outcomes. Journal of Allergy and Clinical Immunology, 121(6), 1301-1308; quiz 1309. Vermani, E., Mittal, R., & Weeks, A. (2009). Pelvic girdle pain and low back pain in pregnancy: A review. Pain Practice, 10(1), 60-71. Koren, G. (2014). T reating morning sickness in the United States— Changes in prescribing are needed. American Journal of Obstetrics and Gynecology, 211(6), 602-606. Koren, G., Clark, S., Hankins, G. D., Caritis, S. N., Umans, J. G., Miodovnik, M., et al. (2015, March 18). Maternal safety of the delayed-release doxylamine and pyridoxine combination for nausea and vomiting of pregnancy; a randomized placebo controlled trial. BMC Pregnancy and Childbirth, 15, 59. Krismer, M., & van Tulder, M. (2007). Strategies for prevention and man-agement of musculoskeletal conditions: Low back pain (non-specific). Best Practice & Research Clinical Rheumatology, 21(1), 77-91. Lacasse, A., Rey, E., Ferreira, E., Morin, C., & Bérard, A., (2008). Validity of a modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scoring index to assess severity of nausea and vomiting of pregnancy. American Journal of Obstetrics and Gynecology, 198(1), 71. e1-e7. Lam, J. R., Schneider, J. L., Zhao, W., & Corley, D. A. (2013). Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA, 310(22), 2435-2442. Lan, Y., T an, H. J., Xing, J. J., Wu, N., Xing, J. J., Wu, F. S., et al. (2015). Auricular acupuncture with seed or pellet attachments for primary insomnia: A systematic review and meta-analysis. BMC Complementary and Alternative Medicine, 15, 103. doi: 10. 1186/s12906-015-0606-7 Luk, C. P., Parsons, R., Lee, Y. P., & Hughes, J. D. (2013). Proton pump inhibitor-associated hypomagnesemia: What do FDA data tell us? Annals of Pharmacotherapy, 47(6), 773-780. Madjunkova, S., Maltepe, C., & Koren, G. (2013). The leading concerns of American women with nausea and vomiting of pregnancy calling Motherisk NVP Helpline. Obstetrics and Gynecology International, 2013, 752980. Mahadevan, U., & Kane, S. (2006). American Gastroenterological Association institute technical review on the use of gastrointestinal medications in pregnancy. Gastroenterology, 131(1), 283-311. Marcuard, S. P., Albernaz, L., & Khazanie, P. G. (1994). Omeprazole therapy causes malabsorption of cyanocobalamin (vitamin B12). Annals of Internal Medicine, 120(3), 211-215. Markovits, N., Loebstein, R., Halkin, H., Bialik, M., Landes-Westerman, J., Lomnicky, J., et al. (2014). The association of proton pump inhibi-tors and hypomagnesemia in the community setting. Journal of Clinical Pharmacology, 54(8), 889-895. Matok, I., Gorodischer, R., Koren, G., Sheiner, E., Wiznitzer, A., & Levy, A. (2009). The safety of metoclopramide use in the first trimester of pregnancy. New England Journal of Medicine, 360(24), 2528-2535. Matok, I., Levy, A., Wiznitzer, A., Uziel, E., Koren, G., & Gorodischer, R. (2012). The safety of fetal exposure to proton-pump inhibitors during pregnancy. Digestive Diseases and Sciences, 57(3), 699-705. Mills, E., Duguoa, J., Perri, D., & Koren, G. (2006). Herbal medicines in pregnancy and lactation: An evidence-based approach. New Y ork: T aylor & Francis. Mitchell, M. D., Gehrman, P., Perlis, M., et al. (2012). Comparative effectiveness of cognitive behavioral therapy for insomnia: A systematic review. BMC family practice. Mørkved, S., Salvesen, K. A., Schei, B., Lydersen, S., & Bø, K. (2007). Does group training during pregnancy prevent lumbopelvic pain? A random-ized clinical trial. Acta Obstetricia et Gynecologica Scandinavica, 86(3), 276-282. 302 CHAPTER 32 | Common Discomforts of Pregnancy
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Vleeming, A., Albert, H. B., Ostgaard, H. C., Sturesson, B., & Stuge, B. (2008). European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), 794-819. Waldum, H. L., Qvigstad, G., Fossmark, R., Kleveland, P. M., & Sandvik, A. K. (2010). Rebound acid hypersecretion from a physiological, pathophysiological and clinical viewpoint. Scandinavian Journal of Gastroenterology, 45(4), 389-394. Weigel, M. M., Reyes, M., Caiza, M. E., T ello, N., Castro, N. P., Cespedes, S., et al. (2006). Is the nausea and vomiting of early pregnancy really feto-protective? Journal of Perinatal Medicine, 34(2), 115-122. West, K. E., Jablonski, M. R., Warfield, B., Cecil, K. S., James, M., Ayers, M. A., et al. (2011). Blue light from light-emitting diodes elicits a dose-dependent suppression of melatonin in humans. Journal of Applied Physiology, 110(3), 619-626. Yamamichi, N., Mochizuki, S., Asada-Hirayama, I., Mikami-Matsuda, R., Shimamoto, T., Konno-Shimizu1, M., et al. (2012). Lifestyle factors affecting gastroesophageal reflux disease symptoms: A cross-sectional study of healthy 19864 adults using FSSG scores. BMC Medicine, 10, 45. doi:10. 1186/1741-7015-10-45. 303 References
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Early in pregnancy estrogen and human placental lactogen (h PL) tend to dominate such that during weeks 8-15 insulin resistance is low, resulting in lower glucose levels, especially in women with type 1  diabetes mellitus (DM). The fasting blood sugar in the normal pregnant woman is lower than in a nonpregnant woman, averaging about 65 mg/d L (Parretti et al., 2001). However, in the fed state, these same hormones cause a resistance to the cellular uptake of glucose by insulin-sensitive tissue, muscle, and fat. This pattern of insulin resis-tance tends to parallel the growth of the fetal-placental unit and the levels of hormones secreted by the placenta. In normal pregnant women, pancreatic β cells respond to insulin resistance by increasing their insulin secretion, resulting in normal circulating glucose levels (Barbour et al., 2007). The fetus does most of its growing in the third trimester of pregnancy. During this time, the fetus is constantly “feeding” I. Intr oduction and general background Normal pregnancy can be viewed as a progressive condition of insulin resistance, hyperinsulinemia, and mild postpran-dial hyperglycemia. The mild postprandial hyperglycemia serves to increase the amount of time that maternal glucose levels are elevated above the basal glucose levels after a meal, thereby increasing the flux of ingested nutrients from mother to the fetus and enhancing fetal growth. During the fasting state (5 hours after food intake), the metabolic processes are relatively the same as the nonpreg-nant state except that they proceed at an accelerated rate. By 10 weeks gestation, placental hormones begin to alter maternal carbohydrate metabolism (T able 33-1). Maribeth Inturrisi Gestat Ional D Iabetes Mell I tus: e arly Detect I on an D Mana G e M ent I n Pre G nancy Table 33-1 Major Placental Hormones and Their Impact on Maternal Carbohydrate Metabolism in All Pregnancies—Normal and with Diabetes Placental Hormone e ffect on c arbohydrate Metabolism Estrogen Increases insulin binding to cells (insulin sensitivity) in early pregnancy, but this effect is cancelled out by increases in progesterone and cortisol in the second half of pregnancy. Progesterone Decreases insulin binding to cells, thus increasing insulin resistance. Human Placental Lactogen (h PL)Induces insulin release from the pancreas but may also contribute to peripheral insulin resistance (in muscle and fat cells). Human Placental Growth Hormone (h PGH)Causes severe peripheral insulin resistance. Tumor Necrosis Factor (TNFα)Has the greatest effect of increasing insulin resistance. Changes in insulin sensitivity correlate specifically with increasing TNFα secretion from 22-35 weeks gestation. TNFα is a cytokine, a proinflammatory agent, which impairs insulin's action of moving glucose from the bloodstream into cells (fat and muscle). In women with gestational diabetes mellitus, this downregulation of insulin action is increased Cortisol Causes gluconeogenesis from the liver increasing glucose in the bloodstream. In addition, it diminishes insulin secretion from the pancreas. Data from Barbour et al. (2007). Cellular mechanisms for insulin resistance in normal pregnancy and gestational diabetes. Diabetes Care, 30 Suppl 2. © Eliks/Shutterstock; © donatas1205/Shutterstock 304 33Chapt Er
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B. Prevalence and incidence Approximately 9. 2% of all pregnancies in the United States are documented to be complicated by diabetes (De Sisto, Kim, & Sharma, 2014). Although 90% of these pregnant women have GDM, a growing number of women (more than 8%) have preexisting type 2 diabetes mellitus (Baptiste-Roberts et al., 2009). The ongoing epi-demic of obesity and the increased ethnic diversity in the United States (African-American, Asian/Pacific Islander, East Indian, Hispanic, and Native American popula-tions) has led to more type 2 diabetes in women of child-bearing age (ACOG, 2005). The number of women entering pregnancy with undiagnosed type 2 diabetes has increased. In addition, it is estimated that 23% of women of childbearing age in the United States have prediabetes, aka glucose intolerance (De Sisto et al., 2014). Two out of three individuals with prediabetes do not know they have it (De Sisto et al., 2014). This translates to women entering pregnancy with undiagnosed diabetes and pre-diabetes potentially placing the fetus at risk for adverse outcomes including miscarriage, birth defects, macroso-mia, and fetal demise. II. Database (may include but is not limited to) In March 2010, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) set forth global recom-mendations to change the way GDM is diagnosed (Metzger et al., 2010). These recommendations are based on data from the prospective double-blinded (patients and providers), epidemiologic study Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) (Metzger et al., 2008). The research subjects were 25,000 pregnant women from around the world who were given a 75-g OGTT at 24-28 weeks gestation to determine at what glucose level adverse outcomes for the fetus occurred. Removal from the study and treatment occurred only if the glucose level reached those consistent with overt diabetes. The Carpenter and Coustan (1982) 3-hour OGTT was designed to determine which women were at increased risk to develop type 2 diabetes in the future, not outcomes for the fetus/newborn. The HAPO study showed that there was a continuous relationship between increasing maternal blood glucose levels and fetal fat deposition and fetal hyper-insulinemia. The proposed glucose values for a positive test were selected when the odds ratio reached 1. 75. These blood glucose values conveyed a 75% increased risk for adverse fetal/neonatal outcomes such as macrosomia, hypoglycemia, and cesarean birth (Metzger et al., 2008, 2010). The IADPSG Consensus Panel translated the results into a one-step clinical practice guideline for the diagnosis of GDM at 24-28 weeks. Ideally all women, but definitely all women but the mother is alternately fasting and feeding. Glucose is transported across the placenta from the mother by facilitated diffusion. The concentration of glucose within the fetus is only slightly lower than maternal glucose. Insulin does not cross the placenta. The fetus synthesizes its own insulin starting at about 9 weeks of gestation. The fetal β cells respond to both an increase in glucose and amino acids. Spikes in maternal glucose cause spikes in fetal insulin production. A. Gestational diabetes mellitus: definition and overview Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with first recognition dur-ing pregnancy with glucose intolerance resolving after delivery of the placenta (World Health Organization [WHO], 2013). This suggests that women who develop gestational diabetes have some defect in carbohydrate metabolism that does not result in hyperglycemia unless exacerbated by a greater demand for insulin produc-tion. Women with GDM cannot overcome the insulin resistance mediated by placental hormones. Pregnancy demands a doubling to tripling of insulin output. It is estimated that women with an abnormal oral glucose tolerance test (OGTT) in pregnancy have at baseline (nonpregnant) impaired function in at least 30-50% of their β cells and thus cannot respond to the increased pregnancy need for insulin secretion. Their fetuses produce insulin in response to the circu-lating glucose levels. Fetal β cells, in turn, hypertrophy in utero initiating a cascade of abnormal metabolic processes resulting in fetal overgrowth and fetal hyperinsulinemia in the short term and in the long term insulin resistance leading to type 2 diabetes (Hillier et al., 2007). T reatment of mild hyperglycemia during pregnancy, aka GDM, has been shown to reduce serious perinatal morbidity (Crowther et al., 2005; Landon et al., 2009). In both of these prospective randomized controlled trials, the rate of large for gestational age newborns and the inci-dence of preeclampsia were cut in half when women were treated for GDM versus not treated. Newborn intensive care admissions were decreased, as were shoulder dysto-cias. These outcomes were achieved without an increase in labor inductions, cesarean delivery, or small for gestational age newborns. In the Crowther study, women in the treat-ment group had a 50% decrease in weight gain during the treatment period and had less postpartum depression than women in the untreated group. GDM is optimally managed by referral to a multidisci-plinary health education team trained and skilled in the management of diabetes during pregnancy. Consultation with a registered dietitian is strongly recommended (American College of Obstetricians and Gynecologists [ACOG], 2013; Crowther et al., 2005). 305 Database
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and diminish insulin secretion. All women should be asked about risk factors at the first prenatal visit (see  T able 33-2). B. Objective/Assessment In the presence of any one of these high-risk factors, ADA recommends that women be tested for undiagnosed type 2 diabetes or prediabetes at the first prenatal visit (ADA, 2015; Metzger et al., 2010). Some providers use the convenience of an A1C, which does not require fasting and can easily be added to the prenatal panel. However, any method to diagnose diabetes or prediabetes in the nonpregnant woman can be used (ADA, 2015). ACOG (2013) suggests using a 1-hour 50-g glucose challenge test (GCT) as an early screen in the first or second trimester. If any early screening is negative, the IADPSG, ADA, ACOG, and U. S. Preventive Services T ask Force (USPSTF, 2014) recommend universal screening at 24-28 weeks by either a one-step method (ADA, 2015; WHO, 2013) or two-step method (ACOG, 2013; Van Dorsten et al., 2013) (T ables 33-3 and 33-4). III. Goals of clinical management A. Identify women at risk and screen for and diagnose both type 2 and gestational diabetes (GDM). B. Reduce adverse fetal and neonatal outcomes through treatment of women with GDM. Incorporate an interdisciplinary approach including nutrition and psychosocial and medical interventions to help women with GDM successfully achieve normal blood glucose levels and decrease perinatal morbidity. C. Educate women with GDM regarding testing for overt diabetes every 1-3 years and about early testing in subsequent pregnancies. D. Encourage women with GDM to continue healthy eating and to be active as well as to reduce weight if overweight or obese to prevent future GDM or overt diabetes. IV. Plan Educate all women with GDM concerning healthy lifestyle behaviors that can result in pregnancy outcomes that closely match those of women without hyperglycemia in pregnancy (American Association of Diabetes Educators [AADE], 2010). A. AADE's 7 Healthy Lifestyle Behaviorswith risk factors, should be screened for type 2 diabetes in the first trimester using one of the standard diagnostic cri-teria for diagnosing diabetes in the nonpregnant population (Metzger et al., 2010). If a woman is found to have a fasting blood glucose (BG) of > 125 mg/d L or an A1C of > 6. 4%, or a random blood glucose of > 199 mg/d L, she should receive a diagnosis of overt, not gestational, diabetes (American Diabetes Association [ADA], 2015). According to the IADPSG recommendations, type 2 diabetes can be diag-nosed during pregnancy and management can be instituted early in order to limit the adverse effects of undiagnosed hyperglycemia. The World Health Organization, the American Diabetes Association, and most countries outside the United States have adopted IADPSG recommendations (ADA, 2015; WHO, 2013). The American College of Obstetricians and Gynecologists (ACOG) did not adopt these guidelines and is awaiting further studies (ACOG, 2013). The National Institutes of Health (NIH) recommended further cost-effective studies and studies in which the improved outcomes could be related to the specific IADPSG testing recommenda-tions (Mission, Ohno, Cheng, & Caughey, 2011). The NIH agreed that we need to adopt a worldwide approach to the diagnosis of GDM to be able to study GDM for best practice management guidelines (Van Dorsten et al., 2013). Both the 2010 IADPSG method (using one step) and the 1982 Carpenter and Coustan method (using two steps) of diagnosing gestational diabetes are presented here and are used in current practice (ACOG, 2013; ADA, 2015). A. Subjective The risk factors (ADA, 2015) for type 2 diabetes, pre-diabetes, and GDM are the same because they share the same pathophysiology of increased insulin resistance Table 33-2 Risk Factors for T ype 2 Diabetes History of insulin-resistant conditions: prediabetes, gestational diabetes, obesity (body mass index > 30), and polycystic ovary syndrome Obstetric and gynecological history: macrosomia, unexplained stillbirth, malformed infant Medications: any medications that adversely affect glucose levels: e. g., corticosteroids, progesterone, and atypical antipsychotics such as Seroquel Family history of overt diabetes among first-degree relatives: mother, father, sister, brother, child Belonging to a high-risk ethnic group: African-American, American Indian, Hispanic/Latina, Asian/Pacific Islander, Southeast Asian, and East Indian, Native American Data from American College of Obstetricians and Gynecologists (2013); American Diabetes Association (2015); Waters, Schultz, Mercer, & Catalano (2009). 306 CHAPTER 33 | Gestational Diabetes Mellitus: Early Detection and Management in Pregnancy
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b. F or a healthy eating plan that incorporates pregnancy and diabetes principles, refer to a registered dietitian who can follow up every 2-3 weeks. c. E ncourage weight gain within the Institute of Medicine (IOM, 2009) recommendations, Table 33-3 Criteria for the Diagnosis of Diabetes or Prediabetes in the Nonpregnant Population test o vert Diabetes Prediabetes A1C The test should be performed in a laboratory using a method that is NGSP-certified and standardized to the Diabetes Control and Complications Trial assay. *≥ 6. 5% ≥ 5. 7%-≤ 6. 4% Fasting plasma glucose Fasting is defined as no caloric intake for at least 8 hours. *≥ 126 mg/d L ≥ 100 mg/d L-≤ 125 mg/d L 2-h plasma glucose during an OGTTThe test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. *≥ 200 mg/d L ≥ 140 mg/d L-≤ 199 mg/d L Random plasma glucose In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis≥ 200 mg/d L   *In the absence of unequivocal hyperglycemia, result should be confirmed by repeat testing. Data from American Diabetes Association. (2015). Classification and diagnosis of diabetes. Position statement: Gestational diabetes mellitus. Diabetes Care, 38 (Suppl. 1), S13-S14. 1. H ealthy eating a. H ealthy eating is the cornerstone of diabetes man-agement (AADE, 2010). Focus on carbohydrate control using the plate method for gestational diabetes (California Diabetes and Pregnancy Program [CDAPP], 2012). Table 33-4 Methods to Diagnose Gestational Diabetes One-Step IADPSG Method* After an 8-12 hour fast, obtain fasting blood glucose (FBG). Administer a 2-hour 75-g OGTT. The patient should remain seated. If any one of the following values are reached or exceeded, the test may be terminated at that time and considered positive. FBG: 92 mg/d L; 1-hr: 180 mg/d L; 2-hr: 153 mg/d L *Note: this method does not include a 50-g glucose challenge test (GCT) (ADA, 2015; WHO, 2013) Two-Step Method Step 1: Administer a 50-g nonfasting GCT. If the result of the GCT is equal to or greater than 180 mg/d L-199 mg/d L, order fasting blood glucose (FBG). If the FBG value is less than 95 mg/d L, perform the 3-hour oral glucose tolerance test (OGTT). If FBG value is equal to or greater than 95 mg/d L, do not perform the OGTT. Elevated FBG of equal to or greater than 95 mg/d L is diagnostic of GDM. Step 2: If the result of the GCT is 140-179 mg/d L, proceed to step 2, a fasting 3-hour 100-g OGTT. Two values equal to or above the following = GDM FBG: 95 mg/d: 1-hr: 180 mg/d L; 2-hr: 155 mg/d L; 3-hr: 140 mg/d L Any one value 200 or above on the OGTT is diagnostic of GDM. Data from American Diabetes Association (2015); World Health Organization (2013); American College of Obstetricians and Gynecologists (2013). 307 Plan
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c. H ave women rate their level of stress, discuss coping strategies, refer to mental health providers as needed. 5. P roblem solving a. H elp women to strategize behaviors that are suc-cessful in achieving normal blood glucose lev-els. Help them make associations between food choices and blood glucose levels and understand what they can control (AADE, 2010). b. T each signs and symptoms of hyperglycemia and how to avoid it. When women are taking secretagogues or insulin, teach them to recog-nize hypoglycemia, how to prevent, and how to treat it (ADA, 2015; CDAPP, 2012). 6. R educing risks a. R eview habits, such as smoking, alcohol, and drugs. b. E ducate concerning tests of fetal well-being such as kick counts, nonstress tests (NST), ultrasounds, and amniotic fluid index (AFI) as needed (CDAPP, 2012). c. I f clinically indicated (size greater than dates, poor blood glucose control, refusal of medica-tion), obtain ultrasound at 32-35 weeks for fetal growth (CDAPP, 2012). d. F or women with GDM A1 (achieves BG control with diet and exercise alone), NST s are not indicated unless there is increased blood pres-sure, macrosomia, history of intrauterine fetal demise, or decreased fetal movement. Women with GDM A1 may continue pregnancy beyond 40 weeks with biweekly NST/AFI testing (CDAPP, 2012). e. F or women with GDM A2 (requires the addition of medication to control blood glucose), NST/ AFI may be started weekly at 32 weeks and biweekly beginning at 36 weeks (CDAPP, 2012). Women with GDM can be allowed a trial of labor for fetus weighing less than 4,500 g (ACOG, 2013). Induction of labor should optimally occur after 39 weeks but before 40 weeks (ACOG, 2013). After 40 completed weeks, studies show that woman with GDM A2 have increased risk of shoulder dystocia and larger babies (Witkop, Neale, Wilson, Bass, & Nicholson, 2009). 7. T aking medications a. Onc e diet and exercise have been optimized, if blood glucose values exceed targets (fasting elevations three times or greater in a week or post meal six times or more in a week), consider adding medication (CDAPP, 2012). When medication is added to treatment, the type of GDM is GDM A2. which have been associated with optimum out-comes for mother and baby (Cheng et al., 2008). d. P repregnancy body mass index should be determined at first visit. Weight gain recom-mendations are determined according to prepregnancy BMI (see Figure 28-6). Weight gain should be followed closely and plotted on the appropriate IOM weight graphs (ACOG, 2005; IOM, 2009). 2. Bein g active a. E xercise increases insulin sensitivity (ACOG, 2002; ADA, 2015). b. E xercise after meals can help keep blood glucose in target range and reduce the need for medication. c. R ecommend regular exercise of at least 30 minutes per day, such as brisk walking (ACOG, 2002; ADA, 2015; Metzger et al., 2007). 3. M onitoring blood glucose (BG) a. M aintaining near normal BG during preg-nancy is associated with reduced macrosomia, preeclampsia, and neonatal hypoglycemia (Crowther et al., 2005; Landon et al., 2009). b. M aternal hyperglycemia during pregnancy has been associated with obesity and type 2 diabetes in their adolescent and adult off-spring (Baptiste-Robert et al., 2009; Dabelea et al., 2008). c. T arget blood glucose of fasting < 90 mg/d L; 1 hour after start of meal < 130 mg/d L is associ-ated with a lower risk for adverse perinatal out-comes (Ehrlich, Crites, Hedderson, Darbinian, & Ferrara, 2010; Metzger et al., 2008). d. W omen who used daily self-monitoring of blood glucose using home glucometer, test strips, and finger-sticking devices had less macrosomia than women who had their BG checked by weekly lab testing only (Hawkins et al., 2009). e. D ocumenting food records and blood glucose results that were reviewed by the providers at each visit was associated with improved blood glucose levels (CDAPP, 2012; Parkin & Davidson, 2009). 4. H ealthy coping a. I ndividuals with diabetes are at greater risk for depression as are pregnant women in general (ACOG, 2006; Kozhimannil, Pereira, & Harlow, 2009). b. U se a standardized depression screening tool for pregnant women (e. g., Edinburgh Postnatal Depression Scale in the early third trimester) (American Academy of Pediatrics, 2015; ACOG, 2006). 308 CHAPTER 33 | Gestational Diabetes Mellitus: Early Detection and Management in Pregnancy
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b. Or al agents (metformin or glyburide) are often effective in managing mild hyperglycemia such as GDM (Balani, Hyer, Rodin, & Shehata, 2009; Dhulkotia, Ola, Fraser, & Farrell, 2010; Langer, 2000; Moore, 2007; Rowan, Hague, Gao, Battin, & Moore, 2008). c. I f insulin is needed in multiple daily injections, referral to a high-risk program may be necessary (CDAPP, 2012; Mathiesen et al., 2012). d. M edical management is beyond the scope of this chapter; therefore, insulin management will not be covered. However, hyperglycemia associ-ated with GDM can often be managed with oral medications as follows:i. M etformin a. B ioavailability: 40-60% b. GI a bsorption complete in 6 hours, peaks in 40 minutes c. N o metabolites, few interactions with other drugs (cimetidine, vitamin B12, guar gum) d. N o liver metabolism, disposed of by the kidney, excreted in 4 hours, half-life 8-12 hours (5% of dose). Administer every 8 or 12 hours. e. S ynergistic action with glyburide and insulin f. M ay have GI side effects such as stom-ach upset, diarrhea, and constipation. Generally, if side effects occur they resolve after a few days. Starting with a low dose (500 mg) reduces side effects. ii. M etformin and pregnancy a. C oncentrations of metformin are lower in pregnancy than nonpregnancy due to increased renal clearance during mid and late pregnancy. b. F etal dose is from negligible to as high as maternal dose c. B reastfed neonate receives < 0. 5% of mother's dose. d. N ot associated with prenatal hypogly-cemia e. U se is associated with less neonatal hypoglycemia after birth. f. N ot associated with lactic acidosis when there is normal renal function. g. E xtended release not as effective as regular metformin iii. M etformin protocol for pregnancy a. Be gin with 500 mg once or twice daily with AM meal or at bedtime with snack depending on the pattern of hyperglycemia. b. I ncrease dose by 500 mg every 3-7 days as limited by GI side effects, until targets reached. c. Obt ain serum creatinine if any suspicion of renal disease. Metformin is cleared entirely by the kidney. iv. Gly buride a. A s ecretagogue (forces insulin out of the beta cells) b. M ay lead to pancreatic exhaustion. c. T wo major metabolites may cross the placenta and result in hypoglycemia and macrosomia in the fetus (Castillo et al., 2015). d. 5 m g peaks in 2-4 hours; take 60 minutes before meal e. H alf-life is 2-4 hours. f. C an be taken TID rather than BID in pregnancy g. A ssociated with hypoglycemia v. Gly buride protocol for pregnancy a. Be gin with 1. 25 mg/day (wt. < 200 lbs. ) b. Be gin with 2. 5 mg/day (wt. > 200 lbs. ) c. T o control post meal elevations, take 60 minutes before meal. d. T o control fasting BG, take at 10 pm-11 pm. e. I ncrease by 1. 25 to 2. 5 mg every 3-7  days until targets reached or max dose of 20 mg/day f. W atch for weight gain g. T each the “rule of 15” to manage hypoglycemiai. I f symptoms of hypoglycemia, check BG ii. I f BG < 70 mg/d L, take 15 g fast-acting (liquid) carbohydrate such as 4 oz of juice or 8 oz milk iii. C heck BG in 15 minutes iv. B G should increase by 15 mg/d L v. I f not, repeat the 15 g fast-acting carbohydrate If either of these oral agents cannot control the fasting BG, a single dose of basal insulin, e. g., Levemir (long acting) or NPH (intermediate acting), at bedtime may be indicated. B. Postpartum management of GDM A1 and GDM A2 1. E ncourage women to continue healthy eating and being active. 2. S trongly encourage breastfeeding to help reduce the risk for future obesity and diabetes in both the mother 309 Plan
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CDPH 4472 B3 Prenatal Weight Gain Grid: Prepregnancy Overweight Range CDPH 4472 B4 Prenatal Weight Gain Grid: prepregnancy Obese Weight Range D. Resources for women with GDM 1. A merican Diabetes Association: 800-342-2383, www . diabetes. org 2. A merican Association of Diabetes Educators: 800-338-DMED, www. diabeteseducator. org/ 3. C enters for Disease Control and Prevention. Division of Diabetes T ranslation: 877-232-3422, www. cdc. gov/diabetes 4. C alifornia Diabetes and Pregnancy Program: Sweet Success: www. cdappsweetsuccess. org/ references American Academy of Pediatrics. (2015). Edinburgh postnatal depression scale. Retrieved from www2. aap. org/sections/scan/practicingsafety /toolkit_resources/module2/epds. pdf. American Association of Diabetes Educators (2010). AADE 7 self-care behav-iors. Retrieved from www. diabeteseducator. org/Professional Resources /AADE7. American College of Obstetricians and Gynecologists. (2002). ACOG Committee opinion. Number 267, January 2002: Exercise during pregnancy and the postpartum period. Obstetrics & Gynecology, 99(1), 171-173. American College of Obstetricians and Gynecologists. (2005). ACOG Committee opinion Number 315, September 2005. Obesity in pregnancy. Obstetrics & Gynecology, 106(3), 671-675. American College of Obstetricians and Gynecologists. (2006). ACOG Committee opinion no. 343: Psychosocial risk factors: Perinatal screening and intervention. Obstetrics & Gynecology, 108(2), 469-477. American College of Obstetricians and Gynecologists. (2009). ACOG Committee opinion no. 435: Postpartum screening for abnormal glucose tolerance in women who had gestational diabetes mellitus. Obstetrics & Gynecology, 113(6), 1419-1421. American College of Obstetricians and Gynecologists. (2013). ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number. 137 August 2013. Gestational diabetes mellitus. Obstetrics & Gynecology, 2013, 122:406-16. American Diabetes Association. (2015). Classification and diagnosis of diabetes. Position statement: Gestational diabetes mellitus. Diabetes Care, 38 (Suppl. 1), S13-S14. Balani, J., Hyer, S. L., Rodin, D. A., & Shehata, H. (2009). Pregnancy outcomes in women with gestational diabetes treated with metformin or insulin: A case-control study. Diabetic Medicine, 26(8), 798-802. Baptiste-Roberts, K., Barone, B. B., Gary, T. L., Golden, S. H., Wilson, L. M., Bass, E. B., et al. (2009). Risk factors for type 2 diabetes among women with gestational diabetes: A systematic review. American Journal of Medicine, 122(3), 207-214, e4. Barbour, L. A., Mc Curdy, C. E., Hernandez, T. L., Kirwan, J. P., Catalano, P. M.,  & Friedman, J. E. (2007). Cellular mechanisms for insulin and the newborn (Feig, Lipscombe, T omlinson, & Blumer, 2011). 3. E ncourage women to get to a normal BMI before conceiving again because obesity confers the same adverse outcomes as diabetes and it increases the risk for GDM and overt diabetes (Roman et al., 2011). 4. E ncourage avoidance of pregnancy at least for 2 years to allow the pancreas to “rest” from insulin resistance. Progesterone-only birth control methods, such as medroxyprogesterone (Depo-Provera), etonogestrel, and progesterone-only pills, have been found to increase the conversion rate of GDM to type 2 diabetes in Hispanic women who were breastfeeding (Kjos et al., 1998). Pregnancy will confer greater insulin resistance than progesterone; therefore, the risks must outweigh the benefits when considering birth control methods. The intrauterine device may be an excellent choice for its effectiveness and length of use. Mirena®, despite using progesterone, has only a local effect on the uterus and has not been shown to increase insulin resistance (Damm, Mathiesen, Petersen, & Kjos, 2007). 5. R eclassify glucose tolerance with the nonpregnant 75-g OGTT (fasting plus 2 hr postprandial) at 6-12 weeks (ACOG, 2009, 2013; ADA, 2015). 6. E ducate women to get checked for diabetes every 1-3 years using the baby's birthday as a reminder. If prediabetes is identified, or age 40 is reached, then obtain a test for diabetes annually (Bellamy, Casas, Hingorani, & Williams, 2009; Ratner et al., 2008). 7. Obt ain an early screen (first visit) for diabetes in future pregnancies (Bentley-Lewis, 2009). 8. A bout 5% of women with GDM have overt diabetes when tested after pregnancy and another 15% have prediabetes. If either is identified, the woman should be referred to a primary care provider or to a diabetes program with educational classes for prediabetes and diabetes. Metformin was shown to reduce the conversion to type 2 diabetes by 58% in women with previous GDM in the Diabetes Prevention Program T rial (Ratner et al., 2008). C. Resources for professionals The prenatal weight gain charts forms are located at the California Department of Public Health (CDPH) website: http://www. cdph. ca. gov/pubsforms/forms/Pages /Maternaland Child Health. aspx CDPH 4472 B1 Prenatal Weight Gain Grid: Prepregnancy Underweight Range CDPH 4472 B2 Prenatal Weight Gain Grid: Prepregnancy Normal Weight Range310 CHAPTER 33 | Gestational Diabetes Mellitus: Early Detection and Management in Pregnancy
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resistance in normal pregnancy and gestational diabetes. Diabetes Care, 30(Suppl. 2), S112-S119. Bellamy, L., Casas, J. P., Hingorani, A. D., & Williams, D. (2009). Type 2 diabetes mellitus after gestational diabetes: A systematic review and meta-analysis. Lancet, 373(9677), 1773-1779. Bentley-Lewis, R. (2009). Gestational diabetes mellitus: An opportunity of a lifetime. Lancet, 373(9677), 1738-1740. California Diabetes and Pregnancy Program (CDAPP). (2012). Guidelines for care. Retrieved from www. cdappsweetsuccess. org/Professionals /CDAPPSweet Success Guidelinesfor Care. aspx. Carpenter, M. W., & Coustan, D. R. (1982). Criteria for screening tests for gestational diabetes. American Journal of Obstetrics and Gynecology, 144, 768-773. Castillo, W. C., Boggess, K., Stürmer, T., Brookhart A., Benjamin, D. K., & Jonsson Funk, M. (2015). Association of adverse pregnancy outcomes with glyburide vs insulin in women with gestational diabetes. JAMA Pediatrics, 169(5), 452-458. doi:10. 1001/jamapediatrics. 2015. 74 Cheng, Y. W., Chung, J. H., Kurbisch-Block, I., Inturrisi, M., Shafer, S., & Caughey, A. B. (2008). Gestational weight gain and gestational diabetes mellitus: Perinatal outcomes. Obstetrics and Gynecology, 112(5), 1015-1022. Crowther, C., Hiller, J., Moss, J., Mc Phee, A., Jeffries, W., & Robinson, J. (2005). Effect of treatment of gestational diabetes mellitus on preg-nancy outcomes from the Australian carbohydrate intolerance study in pregnant women (ACHOIS) trial. New England Journal of Medicine, 352(24), 2477-2486. Dabelea, D., Mayer-Davis, E. J., Lamichhane, A. P., D' Agostino, R. B., Jr., Liese, A. D., Vehik, K. S., et al. (2008). Association of intrauterine exposure to maternal diabetes and obesity with type 2 diabetes in youth: The SEARCH Case-Control Study. Diabetes Care, 31(7), 1422-1426. Damm, P., Mathiesen, E. R., Petersen, K. R., & Kjos, S. (2007). Contraception after gestational diabetes. Diabetes Care, 30(Suppl. 2), S236-S241. De Sisto, C. L., Kim, S. Y., & Sharma, A. J. (2014). Prevalence estimates of gesta-tional diabetes mellitus in the United States. Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Preventing Chronic Disease, 11, 130415. Retrieved from www. cdc. gov/pcd/issues/2014/13_0415 . htm. Dhulkotia, J. S., Ola, B., Fraser, R., & Farrell, T. (2010). Oral hypoglycemic agents vs insulin in management of gestational diabetes: A systematic review and meta analysis. American Journal of Obstetrics & Gynecology, 203(5), 457. e1-9. Ehrlich, S. F., Crites Y. M., Hedderson M. M., Darbinian J. A., & Ferrara, A. (2011). The risk of large for gestational age across increasing categories of pregnancy glycemia. American Journal of Obstetrics & Gynecology, 204(3), 240. e1-6. Feig, D. S., Lipscombe, L. L., T omlinson, G., & Blumer, I. (2011). Breastfeeding predicts the risk of childhood obesity in a multi-ethnic cohort of women with diabetes. Journal of Maternal-Fetal & Neonatal Medicine, 24(3), 511-515. Hawkins, J. S., Casey, B. M., Lo, J. Y., Moss, K., Mc Intire, D. D., & Leveno, K. J. (2009). Weekly compared with daily blood glucose monitoring in women with diet-treated gestational diabetes. Obstetrics & Gynecology, 113(6), 1307-1312. Hillier, T. A., Pedula, K. L., Schmidt, M. M., Mullen, J. A., Charles, M. A., & Pettitt, D. J. (2007). Childhood obesity and metabolic imprinting: The ongoing effects of maternal hyperglycemia. Diabetes Care, 30(9), 2287-2292. Institute of Medicine. (2009). Weight gain during pregnancy: Re-examining the guidelines. Washington, DC: National Academies Press. Kjos, S. L., Peters, R. K., Xiang, A., Thomas, D., Schaefer, U., & Buchanan, T. A. (1998). Contraception and the risk of type 2 diabetes mellitus in Latina women with prior gestational diabetes mellitus. JAMA, 280(6), 533-538. Kozhimannil, K. B., Pereira, M. A., & Harlow, B. L. (2009). Association between diabetes and perinatal depression among low-income mothers. JAMA, 301(8), 842-847. Landon, M. B., Spong, C. Y., Thom, E., Carpenter, M. W., Ramin, S. M., & Casey, B. (2009). A multicenter, randomized trial of treatment for mild gestational diabetes. New England Journal of Medicine, 361(14), 1339-1348. Langer, O., Conway, D. L., Berkus, M. D., Xenakis, E. M., & Gonzales, O. (2000). A comparison of glyburide and insulin in women with gestational diabetes mellitus. New England Journal of Medicine, 343, 1134-1138. Mathiesen, E. R., et al. (2012). Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes. Diabetes Care, 35(10), 2012-2017. Metzger, B. E., Gabbe, S. G., Persson, B., Buchanan, T. A., Catalano, P. A., Damm, P., et al. (2010). International association of diabetes and pregnancy study groups (IADPSG) recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care, 33(3), 676-682. Metzger, B. E., Buchanan, T. A., Coustan, D. R., de Leiva, A., Dunger, D. B., Hadden, D. R., et al. (2007). Summary and recommendations of the Fifth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care, 30(Suppl. 2), S251-S260. Metzger, B. E., Lowe, L. P., Dyer, A. R., T rimble, E. R., Chaovarindr, U., Coustan, D. R., et al. (2008). Hyperglycemia and adverse pregnancy outcomes. New England Journal of Medicine, 358(19), 1991-2002. Mission, J. F., Ohno, M. S., Cheng, Y. W., & Caughey, A. B. (2012). Gestational diabetes screening with the new IADPSG guidelines: A cost-effectiveness analysis. American Journal of Obstetrics and Gynecology, 207(4), 326. e1-e9. Moore, T. R. (2007). Glyburide for the treatment of gestational diabetes. A critical appraisal. Diabetes Care, 30(Suppl. 2), S209-S213. Parkin, C. G., & Davidson, J. A. (2009). Value of self-monitoring blood glucose pattern analysis in improving diabetes outcomes. Journal of Diabetes Science T echnology, 3(3), 500-508. Parretti, E., Mecaci, F., Papini, M., Cioni, R., Carignani, L., Mignosa M., et al. (2001). Third-trimester maternal blood glucose levels from diurnal profiles in nondiabetic pregnancies. Correlation with sonographic parameters of fetal growth. Diabetes Care, 24, 1319-1323. Ratner, R. E., Christophi, C. A., Metzger, B. E., Dabelea, D., Bennett, P. H., Pi-Sunyer, X., et al. (2008). Prevention of diabetes in women with a history of gestational diabetes: Effects of metformin and lifestyle interventions. Journal of Clinical Endocrinology and Metabolism, 93(12), 4774-4779. Roman, A. S., et al. (2011). The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes. Journal of Maternal. Fetal & Neonatal Medicine, 24(5), 723-727. Rowan, J. A., Hague, W. M., Gao, W., Battin, M. R., & Moore, M. P. (2008). Metformin versus insulin for the treatment of gestational diabetes. New England Journal of Medicine, 358(19), 2003-2015. 311 References
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Waters, T. P., Schultz, B. A. H., Mercer, B. M., & Catalano, P. M. (2009). Effect of 17alpha-hydroxyprogesterone caproate on glucose intolerance in pregnancy. Obstetrics and Gynecology, 114(1), 45-49. Witkop, C., Neale, D., Wilson, L. M., Bass, E. B., & Nicholson, W. K. (2009). Active compared with expectant delivery management in women with gestational diabetes: A systematic review. Obstetrics and Gynecology, 113(1), 206-217. World Health Organization. (2013). Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy. Geneva: Author. U. S. Preventive Services T ask Force. (2014). Final recommendation statement: Gestational diabetes: Screening. http://www. uspreventiveser-vicestaskforce. org/Page/Document/Recommendation Statement Final /gestational-diabetes-mellitus-screening. Van Dorsten, J. P., et al. (2013, March 4-6). Diagnosing gestational diabetes mellitus. National Institutes of Health Consensus Development Conference Statement (NIH Consensus State Statements Vol. 29, No. 1). Bethesda, MD: National Institutes of Health, U. S. Department of Health and Human Services. 312 CHAPTER 33 | Gestational Diabetes Mellitus: Early Detection and Management in Pregnancy
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The etiology of preeclampsia-eclampsia is largely unknown but multifactorial with suspected genetic and immunologic pathways and several identified predisposing risk factors. The pathophysiology of preeclampsia involves abnormal devel-opment of placental vascularization and impaired implan-tation, which often contributes to reduced perfusion and uteroplacental insufficiency. Placental ischemia triggers the release of inflammatory and oxidative stress factors that cause endothelial dysfunction resulting in the classic manifesta-tions of preeclampsia, including hypertension. Preeclampsia typically progresses in severity as pregnancy advances with a variable rate that cannot be reliably predicted. The disease can be resolved only through birth of the infant and placenta but recovery does not occur immediately; symptoms may present or worsen in the first 24-48 hours postpartum, and new diag-noses have been reported up to 6 weeks later (ACOG, 2013; Ananth et al., 2013; Henderson et al., 2014; Sibai, 2012). There is no reliable predictive model for preeclampsia and few preventative measures with demonstrable efficacy (ACOG, 2013). Daily low-dose aspirin therapy (81 mg) beginning late in the first trimester may reduce the risk of preeclampsia by 10-24% in high-risk populations of clients reviewed in T able 34-2 (Henderson et al., 2014). Women living in low-income countries are more likely to have low dietary intake of calcium than those living in high-income countries (Hofmeyr et al., 2014). Oral calcium supplemen-tation may reduce preeclampsia incidence among women with low dietary intake (< 600 mg/day) and should be considered for clients with a history of diagnosis in prior pregnancies, keeping in mind that excessive calcium may be harmful (Hofmeyr et al., 2014; Rath & Fischer, 2009; Schoenaker, Soedamah-Muthu, & Mishra, 2014; Sibai, 1998, 2005). Preeclampsia prevention with supplemental vitamins C, E, and D remains controversial and lacks strong evidence to support routine or targeted recommendations (ACOG, 2013; Dodd, O'Brien, & Grivell, 2014; Weinert & Silveiro, 2015). A prepregnancy diet low in these vitamins may increase the risk of preeclampsia, and physical activity may be protective (ACOG, 2013). Thus, health education I. Intr oduction and general background Preeclampsia-eclampsia is typically characterized by hyper-tension and proteinuria occurring after 20 weeks gestation with an impact on multiple organ systems and likelihood of disease progression over time (American College of Obstetricians and Gynecologists [ACOG], 2013). Preeclampsia occurs in 3-6% of pregnancies in the United States (Ananth, Keyes, & Wapner, 2013) and is a significant risk factor for adverse perinatal out-comes. Approximately 17% of maternal deaths are related to hypertensive disorders in pregnancy (Druzin, Shields, Peterson, & Cape, 2014), including preeclampsia-eclampsia, which has a disparate racial impact for reasons not yet well defined. African-Americans have a rate of preeclampsia that is 1. 65 times greater than Caucasians in the United States (Henderson et al., 2014; T anaka et al., 2007). Hypertensive disorders in pregnancy are outlined in T able 34-1 and include chronic hypertension with superimposed preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. These diagnoses are beyond the scope of this chapter, which is focused on the diagnosis and evidence-based management of preeclampsia-eclampsia. Preeclampsia typically includes the finding of both hyper-tension and proteinuria, but the presence of proteinuria is not required for diagnosis. In the absence of proteinuria, preeclampsia can be diagnosed in the setting of hyperten-sion plus end-organ involvement indicating severe disease and evidenced by abnormal laboratory values (thrombocyto-penia, elevated liver enzymes, or elevated serum creatinine), physical examination findings, or client symptomatology. Preeclampsia must be differentiated from gestational hyper-tension, which occurs after 20 weeks gestation and is defined as a systolic blood pressure greater than or equal to 140 mm Hg and/or diastolic blood pressure greater than or equal to 90 mm Hg, observed on at least two occasions at a minimum of 4 hours apart in the absence of proteinuria or end-organ involvement. Kim Q. Dau and Jenna Shaw-Battista Hyperten SIon In pregnancy: p reeclamp SI a-e clamp SI a© Eliks/Shutterstock; © donatas1205/Shutterstock 31334Chapt Er
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placental abruption, stroke, pulmonary edema, myocardial infarction, and coagulopathy. Fetal and neonatal sequelae of severe disease may include fetal growth restriction and still-birth. Preeclampsia also contributes to the iatrogenic preterm birth rate because management includes facilitating delivery with induction of labor or cesarean delivery prior to labor in the case of severe disease with rapid progression. Early detection and management can reduce adverse perinatal outcomes and may improve long-term mater-nal cardiovascular health (Druzin et al., 2014; Sibai, 2005). Preeclampsia-eclampsia is associated with a two-to threefold increased risk of cardiovascular disease overall and increased relative risks for chronic hypertension, ischemic heart disease, focused on nutrition and exercise may be particularly helpful before conception and in early pregnancy. In the absence of severe features, preeclampsia diagnosed and treated at or near term is unlikely to be associated with significant perinatal complications (Sibai, 2005). However, maternal and neonatal morbidities are likely to result from severe gestational hypertension or preeclampsia, particularly prior to 34 weeks of gestation. Timely recognition and treat-ment are necessary to prevent progression to eclampsia, which is diagnosed when maternal grand mal seizures occur and is strongly associated with adverse outcomes including maternal and fetal death (Sibai, 2005). Maternal morbidity resulting from preeclampsia with severe features is rare and includes Table 34-1 Hypertensive Disorders in Pregnancy Diagnosis c riteria Chronic hypertension Blood pressure ≥ 140/90 (two measurements at least 4 hours apart) with onset prior to 20 wk gestation; typically predates the pregnancy. Gestational hypertension Blood pressure ≥ 140/90 (two measurements at least 4 hours apart) with onset after 20 wk gestation; no proteinuria; resolves by 6 weeks postpartum. Preeclampsia Gestational hypertension in the presence of proteinuria (at least 1+ on urine dipstick OR ≥ 0. 3 mg/d L on spot protein/creatinine ratio OR ≥ 300 mg in 24-hour urine collection), OR Gestational hypertension in the absence of proteinuria AND presence of at least one of the following: Pulmonary edema Cerebral or visual symptoms Thrombocytopenia (platelets < 100,000/m L) ≥ 1. 1 mg/d L or a doubling of serum creatinine concentration Twice the normal concentration of aspartate aminotransferase (AST) or alanine aminotransferase (ALT) Preeclampsia with severe features Presence of preeclampsia with any of the following: Blood pressure ≥ 160/110 (two measurements at least 4 hours apart) Pulmonary edema Cerebral or visual symptoms Thrombocytopenia (platelets < 100,000/m L) ≥1. 1 mg/d L or a doubling of serum creatinine concentration Twice the normal concentration of AST or ALT Chronic hypertension with superimposed preeclampsia Chronic hypertension in the setting of: New onset or increased proteinuria Sudden increase in blood pressure Sudden manifestation or worsening of lab abnormalities Onset of severe headaches, cerebral or visual symptoms, pulmonary edema, right upper quadrant pain HELLP syndrome Considered preeclampsia subtype; characterized by hemolysis, elevated liver enzymes, low platelets Postpartum preeclampsia Preeclampsia occurring in the postpartum period prior to 6 months postpartum Eclampsia New-onset grand mal seizures with preeclampsia in pregnancy or postpartum Data from American College of Obstetricians and Gynecologists. (2013). Hypertension in pregnancy. Washington, DC: American College of Obstetricians and Gynecologists. 314 CHAPTER 34 | Hypertension in Pregnancy: Preeclampsia-Eclampsia
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a. M edical history: Body mass index > 35, diabetes, or chronic hypertension, renal, vascular, or autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome. b. Obs tetric and gynecological history: First pregnancy, maternal age > 40 years, mul-tiple gestation, in vitro fertilization, or history of preeclampsia, placental abruption, or fetal growth restriction. 2. F amily history: a. M other or sister with hypertensive disorder in pregnancy 3. R eview of systems: a. C onstitutional signs and symptoms: Decreased fetal movement, report of feeling unwell, e. g., fatigued, malaise, dizzy, light headed, anxious, or confused. b. Sk in: Unexplained ecchymosis. venous thromboembolism, stroke, and mortality 5-15 years after the affected pregnancy (Bellamy, Casas, Hingorami, & Williams, 2007). Clients with preeclampsia in pregnancy are also at greater risk for postpartum depression and posttraumatic stress disorder following childbirth (Senden et al., 2012). II. Database (may include but is not limited to) A. Subjective Assess for the presence of risk factors and symptoms. Clients presenting with vague symptoms such as headache, visual disturbances, abdominal pain, shortness of breath, generalized swelling, and complaints of “I just don't feel right” should be evaluated for atypical preeclampsia pre-sentations and severe disease features due to the variable presentation of this serious complication of pregnancy (Sibai & Stella, 2009). 1. P ast health history Table 34-2 Clinical Risk Assessment for Preeclampsia and Use of Low-Dose Aspirin risk level r isk Factors r ecommendation High† History of preeclampsia, especially when accompanied by an adverse outcome Multifetal gestation Chronic hypertension Type 1 or 2 diabetes Renal disease Autoimmune disease (systemic lupus erythematosus, antiphospholipid syndrome)Recommend low-dose aspirin if the patient has ≥ 1 of these high-risk factors Moderate‡ Nulliparity Obesity (body mass index > 30 kg/m 2) History of preeclampsia in mother or sister Sociodemographic characteristics (African-American race, low socioeconomic status) Age ≥ 35 years Personal history factors (e. g., low birthweight or small for gestational age, previous adverse pregnancy outcome, > 10-year pregnancy interval)Consider low-dose aspirin if the patient has several of these moderate-risk factors Low Previous uncomplicated full-term delivery Do not recommend low-dose aspirin †Single risk factors that are consistently associated with the greatest risk for preeclampsia. The preeclampsia incidence rate would be approximately ≥ 8% in a pregnant woman with ≥ 1 of these risk factors. ‡ A combination of multiple moderate-risk factors may be used by clinicians to identify women at high risk for preeclampsia. These risk factors are independently associated with moderate risk for preeclampsia, some more consistently than others. Reproduced from U. S. Preventative Services Task Force. (2014). Final Recommendation Statement: Low Dose Aspirin to Prevent Preeclampsia: Preventive Medication. Retrieved from http://www. uspreventiveservicestaskforce. org/Page/Document/Recommendation Statement Final /low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication#tab315 Database
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c. Ey es: Visual disturbances including blurred vision, “spots,” “stars,” “flashing lights,” or blindness (indicative of retinal detachment). d. R espiratory and cardiovascular: Shortness of breath or dyspnea (may indicate concomitant pulmonary edema); increased swelling, particularly facial or periorbital. e. G astrointestinal: Epigastric pain or pain in the right upper quadrant of the abdomen, heartburn, nausea, or vomiting. f. Ge nitourinary: Decreased urinary output, vaginal bleeding (may indicate abruptio placentae resulting from severe hypertension). g. N eurologic: Paresthesia of hands, feet, or extremities (may accompany significant edema); report of seizure; change in mental status or loss of conscious-ness. Headaches, particularly with new onset or increased severity or frequency. Headaches associated with preeclampsia are often frontal or occipital and do not respond to conservative treatment, e. g., over-the-counter medication such as acetaminophen. B. Objective 1. V ital signs a. B lood pressure greater than or equal to 140  mm Hg systolic and/or 90 mm Hg diastolic on at least two occasions more than 4 hours apart. If blood pressure is greater than or equal to 160 mm Hg systolic and/or 110 mm Hg diastolic, confirm with repeat measurement within min-utes to ensure timely management of severe hypertension (see T able 34-3). b. R apid and excessive weight gain (> 2 pounds per week)2. S kin examination: Petechiae, ecchymosis, or jaundice (may be present with hemolysis or thrombocytopenia). 3. C ardiovascular examination: Generalized edema, particularly facial or periorbital, with or without pitting. 4. A bdominal examination: a. L iver may be enlarged b. R ight upper quadrant abdominal pain c. F undal height; if less than expected for gesta-tional age, ultrasound imaging may be indicated to assess for oligohydramnios or fetal growth restriction, which may result from maternal hypertension. d. F etal heart tones 5. Ge nitourinary: Proteinuria of greater than or equal to 1+ protein on macrourinalysis with a clean, midstream sample. Refer to T able 34-1 for subsequent proteinuria measurement options and diagnostic criteria. 6. N eurologic examination: Hyperreflexia, with or without clonus. III. a ssessment A. Determine the diagnosis 1. C riteria for preeclampsia diagnosis: Gestational hypertension and either proteinuria or evidence of severe features with end-organ involvement. In the absence of proteinuria, preeclampsia is diagnosed in the setting of gestational hypertension and at least one of the following: pulmonary edema; cerebral or visual symptoms, thrombocytopenia (platelets < 100,000/m L); at least 1. 1 mg/d L or a doubling of serum creatinine concentration; or twice the normal concentration of aspartate AST or ALT, as described in T able 34-1. Table 34-3 Steps for Obtaining Accurate Blood Pressure Measurements To Assure an Accurate Blood Pressure Measurement: Obtain correct size cuff that encircles 80% of the arm Assess for caffeine or nicotine consumption within 30 minutes Be sure patient is sitting or semi-reclining with back supported and feet flat on floor (not dangling) Place cuff on bare upper arm without restrictive clothing, with arm supported at heart level Auscultation is most accurate. If auscultating: use first audible sound (Korotkoff I) as systolic pressure and use disappearance of sound (Korotkoff V) as diastolic pressure For accuracy, a second reading should be taken within 15 minutes in the same position and the highest reading recorded If reading is greater than or equal to 140/90 on repeat, further evaluation for preeclampsia is warranted Documentation should include the arm in which the blood pressure was taken316 CHAPTER 34 | Hypertension in Pregnancy: Preeclampsia-Eclampsia
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position, using an appropriately sized sphygmoma-nome ter cuff. Proper blood pressure assessment is essential and outlined in T able 34-3. Gestational hypertension is diagnosed when two or more elevated readings are observed greater than 4 hours apart. In case of hypertensive emergency in pregnant or postpartum clients, it is not advisable to wait for at least two elevated blood pressure readings in 4 hours before initiating treatment. In case of acute onset or persistent (lasting 15 minutes or more) and severe systolic (≥ 160 mm Hg) and/or diastolic (≥  110  mm Hg) hypertension, treat with antihypertensives within 30-60 minutes if blood pressures remain elevated 15  minutes after the initial severe finding (ACOG, 2015). 2. Obt ain a clean midstream urine sample to assess for protein on standardized laboratory macrourinalysis if not previously done. Inconsistencies in qualitative assessment of macrourinalysis via dipstick suggest this method of diagnosis should be avoided, but in low-resource settings, a urine dipstick reading of 1+ is sufficient for diagnosis of proteinuria if found on two or more occasions, at least 4 hours apart (Druzin et al., 2014). Consider urine culture and sensitivity to rule out urinary tract infection if proteinuria is present because asymptomatic infection is common in pregnancy and could confound the diagnosis. 3. I nitiate 24-hour urine collection or spot urine protein/ creatinine ratio to assess for proteinuria if the client has gestational hypertension or 1+ protein on urine dipstick. The 24-hour urine collection for protein measurement remains the gold standard for proteinuria diagnosis but the spot protein/creatinine ratio provides a reliable estimate and is recommended as a less burdensome proxy (Papanna, Mann, Kouids,  & Glantz, 2008). A protein/creatinine ratio greater than or equal to 0. 3 mg/d L OR a 24-hour urine collection with protein levels equal to or greater than 300 mg is diagnostic of preeclampsia in a hypertensive pregnant client (ACOG, 2013). 4. Or der serum testing: complete blood count (CBC) with platelets, and liver function panel including AST, ALT, serum protein, and creatinine. Note that alkaline phosphatase is typically elevated in pregnancy and is not indicative of preeclampsia. Although commonly ordered, uric acid has a 33% positive predictive value and is not a useful diagnostic tool (ACOG, 2013). Lactate dehydrogenase (LDH) and bilirubin levels may be useful in detecting hemolysis associated with HELLP syndrome, in addition to thrombocytopenia assessment (Druzin et al., 2014). B. Treatment and follow-up of gestational hypertension or preeclampsia without severe features2. Di fferential diagnosis: If criteria are not met, the differential diagnosis should include but is not limited to impending preeclampsia, chronic or gestational hypertension, liver or renal disease, and substance use (Sibai & Stella, 2009). Similarly, HELLP syndrome should be considered, especially when hemolysis (H), elevated liver enzyme levels (EL), or low platelet counts (LP) are observed. B. Severity In 2013 the American College of Obstetricians and Gynecologists described the following severe features of preeclampsia: 1. B lood pressure of at least 160 mm Hg systolic or 110 mm Hg diastolic on two occasions at least 4 hours apart while the client is on bed rest. 2. N ew-onset cerebral or visual disturbances 3. P ulmonary edema 4. I mpaired liver function (twice normal concentration of ALT or AST) 5. Thr ombocytopenia (< 100,000/m L) 6. R enal insufficiency: Elevated serum creatinine (> 1. 1 mg/d L or a doubling of serum creatinine concentration) IV. g oals of clinical management A. Screening Screen all pregnant women for risk factors at the first prenatal visit and with blood pressure checks at each prenatal visit. B. Prevention T reat women at high risk with low-dose aspirin therapy. C. Identification Order appropriate diagnostic laboratory tests when blood pressure is elevated and educate all pregnant women of preeclampsia symptoms. D. Maternal and fetal well-being Assure maternal and fetal well-being with blood pres-sure, urine, and symptom monitoring, fetal surveillance methods, and growth ultrasounds. Plan for induction of labor at appropriate gestational age for diagnosis. V. p lan A. Diagnostic tests 1. R epeat blood pressure assessment after a 10-30 minute rest period with the client in an upright or sitting 317 Plan
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1. D elivery is recommended after 37 weeks gestation after physician consultation; comanagement may be appropriate. 2. I f less than 37 weeks gestation, stable clients may receive outpatient care with maternal and fetal surveillance to identify disease progression and development of severe features (ACOG, 2013; Druzin et al., 2014). a. F etal surveillance and management i. T wice-weekly biophysical profile (BPP) or nonstress test (NST) plus amniotic fluid index (AFI) is recommended. ii. U ltrasound assessment of fetal growth is recommended upon diagnosis and at 3-week intervals. b. M aternal surveillance and management (ACOG, 2013; Druzin et al., 2014)i. B lood pressure, proteinuria, and signs/ symptom review (severe headache, visual changes, epigastric or right upper quadrant pain, shortness of breath) should be evalu-ated twice weekly, to monitor for develop-ment of severe features. ii. L aboratory testing may be repeated weekly or with worsening symptomatology: CBC, ALT/AST, serum creatinine (ACOG, 2013). iii. The re is no compelling evidence that bed rest reduces disease progression or improves perinatal outcomes. However, the left lateral recumbent position may opti-mize uterine, placental, and fetal circula-tion and should be encouraged, particularly if significant edema is present. iv. C onsider home blood pressure monitoring and recording if clients with nonsevere pre-eclampsia are being managed on an outpa-tient basis. v. Dur ing return visits, complete a review of systems and physical exam as previously described. Discuss parameters for acute reevaluation and ensure client has appoint-ments for subsequent fetal and maternal surveillance. c. On going medical consultation about evolving client condition and collaborative management plan. C. Treatment and follow-up of severe preeclampsia 1. T reatment and follow-up of severe preeclampsia requires immediate physician consultation and probable referral to obstetrician or perinatology services. 2. I f less than 34 weeks gestation, clients should be admitted to a tertiary facility. Corticosteroids should be considered to enhance fetal lung development during expectant management, which is recommended in the absence of indications for immediate delivery. Severe cases at early gestational ages are more likely to progress rapidly with worse outcomes than later cases, necessitating ongoing surveillance and anticipatory guidance for the family. 3. D elivery is recommended at 34 or more weeks gestation. 4. T o minimize risk of maternal stroke, antihypertensives should be administered as soon as possible for those individuals with blood pressure greater than or equal to 160 mm Hg systolic or above 105 mm Hg diastolic (Druzin et al., 2014). D. Client education in the setting of suspected or confirmed preeclampsia 1. Adv ise the client to immediately report signs of severe preeclampsia: Severe headache, visual changes, epigastric or right upper quadrant pain, or shortness of breath. 2. T each the client how to perform fetal kick counts twice daily after 28 weeks gestation. Instruct the client to notify providers if fewer than 10 fetal movements are felt in a 2-hour period, preferably when client is at rest following a meal. 3. I f home blood pressure monitoring is initiated, teach the client how to use the machine and record values. Instruct the client to immediately report critical values (≥ 160/105 mm Hg). 4. Di scuss self-care including nutrition, hydration, exercise, stress management, and relaxation. 5. P rovide anticipatory guidance about disease progression and both immediate and long-term sequelae. 6. C learly document the follow-up plan and include the client in the decision-making process. 7. P rovide anticipatory guidance regarding the recommendation of induction of labor in the setting of severe and nonsevere preeclampsia (ACOG, 2013). Encourage individualized care planning with medical providers, taking into consideration the client's own values and judgments (ACOG, 2013). E. Consultation and referral Refer to Chapter 30, Guidelines for Medical Consultation, Interprofessional Collaboration, and T ransfer of Care During Pregnancy and Childbirth. Physician consultation is indicated for suspected or documented preeclampsia 318 CHAPTER 34 | Hypertension in Pregnancy: Preeclampsia-Eclampsia
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Maternal Quality Care Collaborative toolkit to transform maternity care). Stanford, CA: California Maternal Quality Care Collaborative. Henderson, J. T., Whitlock, E. P., O'Connor, E., Senger, C. A., Thompson, J. H., & Rowland, M. G. (2014). Low-dose aspirin for prevention of morbidity and mortality from preeclampsia: A systematic evidence review for the U. S. Preventive Services T ask Force. Annals of Internal Medicine, 10, 695-703. Hofmeyr, G. J., Belizan, J. M., von Dadelszen, P., & Calcium and Pre-eclampsia Study Group. (2014). Low-dose calcium supplementation for preventing pre-eclampsia: A systematic review and commentary. British Journal of Obstetrics and Gynaecology, 8, 951-957. Ogedegbe, G., & Pickering, T. (2010). Principles and techniques of blood pressure measurement. Cardiology Clinics, 28(4), 571-586. Papanna, R., Mann, L. K., Kouids, R. W., & Glantz, J. C. (2008). Protein /creatinine ratio in preeclampsia. Obstetrics & Gynecology, 112(1), 135-144. Peters, R. M. (2008, October-November). High blood pressure in pregnancy. Nursing for Women's Health, pp. 410-422. Rath, W., & Fischer, T. (2009). The diagnosis and treatment of hypertensive disorders of pregnancy: New findings for antenatal and inpatient care. Deutsches Ärzteblatt International, 106(45), 733-738. Schoenaker, D., Soedamah-Muthu, S. S., & Mishra, G. D. (2014). The association between dietary factors and gestational hypertension and pre-eclampsia: A systematic review and meta-analysis of observational studies. BMC Medicine, 1, 157. Senden, I. P., Duivenvoorden, H. J., Filius, A., De Groot, C. J., Steegers, E. A., & Passchier, J. (2012). Maternal psychosocial outcome after early onset preeclampsia and preterm birth. Journal of Maternal Fetal Neonatal Medicine, 25, 272-276. Sibai, B. M. (1998). Prevention of preeclampsia: A big disappointment. American Journal of Obstetrics & Gynecology, 179, 1275-1278. Sibai, B. M. (2005). Diagnosis, prevention, and management of eclampsia. Obstetrics & Gynecology, 105(2), 402-410. Sibai, B. M. (2012). Etiology and management of postpartum hypertension-preeclampsia. American Journal of Obstetrics and Gynecology, 203(6), 470-475. Sibai, B. M., & Stella, C. L. (2009). Diagnosis and management of atypical preeclampsia-eclampsia. American Journal of Obstetrics and Gynecology, 200(5), e481-e487. T anaka, M., Jaamaa, G., Kaiser, M., Hills, E., Soim, A., Zhu, M., et al. (2007). Racial disparity in hypertensive disorders of pregnancy in New Y ork State: A 10-Y ear longitudinal population-based study. American Journal of Public Health, 97(1), 163-170. doi:10. 2105/AJPH. 2005. 068577. U. S. Preventive Services T ask Force. (2014). Final recommendation state-ment. Low dose aspirin to prevent preeclampsia: Preventive medica-tion. Retrieved from www. uspreventiveservicestaskforce. org/Page /Document/Recommendation Statement Final/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication. Weinert, L. S., & Silveiro, S. P. (2015). Maternal-fetal impact of vitamin D deficiency: A critical review. Maternal and Child Health Journal, 19(1), 94-101. doi: 10. 1007/s10995-014-1499-7. of any severity. Gestational hypertension and nonsevere preeclampsia may be managed by nurse practitioners or nurse-midwives with physician consultation, or collab-oratively managed on either an inpatient or outpatient basis. Severe preeclampsia at any gestational age warrants evaluation by an obstetrician as soon as possible, and typi-cally requires referral to obstetrical care or a maternal-fetal medicine service. F. Postpartum and preconception considerations (ACOG, 2013; Druzin et al., 2014) 1. P ostpartum follow-up is recommended to monitor blood pressure at 72 hours and 7-10 days postpartum. 2. P reeclampsia is associated with greater risk of lifelong cardiovascular disease, which may be lessened with healthy lifestyle changes. 3. A ny client with a history of preeclampsia should be advised of the risk of recurring preeclampsia in subsequent pregnancy and the availability of low-dose aspirin therapy to reduce the risk of recurrence. 4. I n the preconception period, clients with obesity, chronic hypertension, renal disease, diabetes, or autoimmune disease should be advised of the potential risk of preeclampsia and be provided support to improve health and reduce risks of pregnancy complications. re Ference S American College of Obstetricians and Gynecologists. (2013). Hypertension in pregnancy. Washington, DC: American College of Obstetricians and Gynecologists. American College of Obstetricians and Gynecologists. (2015). ACOG Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia. Obstetrics and Gynecology, 125(2), 521-525. Ananth, C. V., Keyes, K. M. & Wapner, R. J. (2013). Pre-eclampsia rates in the United States, 1980-2010: Age-period-cohort analysis. BMJ, 347(15), f6564. doi: 10. 1136/bmj. f6564. Bellamy, L., Casas, J. P., Hingorami, A. D., & Williams, D. (2007). Preeclampsia and risk of cardiovascular disease and cancer in later life: Systematic review and meta-analysis. British Medical Journal (Clinical Research Edition), 335(7627), 974-982. Dodd, J. M., O'Brien, C., & Grivell, R. M, (2014). Preventing pre-eclampsia are dietary factors the key? BMC Medicine, 12, 176. doi:10. 1186 /s12916-014-0176-4 Druzin, M. L., Shields, L. E., Peterson, N. L., & Cape, V. (2013). Preeclampsia toolkit: Improving health care response to preeclampsia (California 319 References
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Asians who have the lowest rate (16. 5% and 10%, respec-tively), and uninsured women have a rate of nearly 20%. Two-thirds of preterm births are spontaneous and the other one-third are for indicated reasons. It has been noted that, as the rate of indicated late preterm births increased, the rate of stillbirths has decreased. II. Database (may include but it not limited to) A. Subjective 1. R eproductive history a. P rior spontaneous preterm birth (s PTB) (singleton live birth at 16 0/7-36 6/7 weeks gestation or stillbirth before 24 weeks present-ing as labor, ruptured membranes, advanced cervical dilatation)—this is the most important risk factor for s PTB. b. R isk of PTB in a subsequent pregnancy after one prior s PTB in a singleton pregnancy is 15%; this risk increases to 33% with two prior s PTBs and is 24% if a woman had a term pregnancy followed by a s PTB (Adams, Elam-Evans, Wilson, & Gilbertz, 2000). c. S pontaneous abortions if recurrent and in second trimester 2. G ynecological history a. P resence of a uterine malformation (müllerian anomalies) b. P revious cervical cone biopsy or excision with loop electrosurgical excision procedure (LEEP) 3. M edical history (puts a woman more at risk for indicated preterm birth) a. T ype 1 diabetes—not well controlled especially preconception I. Intr oduction and general background Twelve percent of births in the United States occur before 37 weeks. Preterm birth is the leading cause of neonatal mortality (American College of Obstetrics and Gynecology [ACOG], 2012). The birth of a premature infant can lead to long-term health consequences such as cerebral palsy and lung, hearing, and vision problems, and new evidence shows an increase in adult diseases such as cardiovascular disease and diabetes. Unfortunately, there are large differ-ences in the burden of prematurity by race/ethnicity with African-Americans having the highest rate. Premature births (PTB) have a large economic impact, averaging more than $54,000 in medical costs per premature infant and 10 times the medical expenses in the first year of life compared to term infants (Behrman & Butler, 2006). A. Definition A PTB is any birth that occurs after 20 weeks gestation and prior to 37 completed weeks of gestation (36 6/7 weeks). Preterm births are further classified into: 1. ex tremely preterm (< 28 weeks) 2. v ery preterm (28 to < 32 weeks) 3. mode rate to late preterm (32 to < 37 weeks). B. Prevalence/Incidence The current rate of premature birth is 11. 7%, an 11% decrease from 2006 but still higher than the Healthy People 2020 goal of 9. 6% and higher than that in European nations (Martin, Hamilton, & Osterman, 2014). Recent progress in preventing iatrogenic late preterm births is one reason for the decrease. The num-ber of multiple births has remained stable, which is good news because the vast majority are born prematurely. Significant sociodemographic differences in prematurity still exist. African-Americans have a 65% higher rate than Mary Barger Preter M La Bor Manage Ment© Eliks/Shutterstock; © donatas1205/Shutterstock 320 35Chapt Er
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IV. g oals of clinical management A. Identification Determine through screening and history women at risk for preterm labor. B. Prevention Reduce preterm labor and birth rates by using interven-tions aimed at individual identified risk factors. C. Treatment Refer women with previous PTB for progesterone sup-plementation and serial cervical length assessments. Identify preterm labor early and refer to hospital birth unit to ensure betamethasone treatment to aid in fetal lung maturity. V. Plan A. Women at risk for preterm labor 1. S creen all pregnant women for asymptomatic bacteriuria at initial presentation and treat if positive urine culture to prevent pyelonephritis 2. A void poor nutrition: a. I f BMI < 19, ensure the woman knows recom-mended weight gain in pregnancy and refer to nutritionist if needed. b. E nsure that women eat a Mediterranean-type diet low in fat and processed food, rich in fruits and vegetables, and two servings of fatty fish a week or take omega-3 supplements of 1-1. 5 grams a day (Khoury, Henriksen, Christophersen, & T onstad, 2005). 3. E nsure that women have adequate levels of vitamin D (greater than 20 ng/m L). There is moderate evidence of a relationship between vitamin D levels and risk of spontaneous and indicated preterm birth (Bodnar et al., 2014; Robinson et al., 2013; Wei, Qi, Luo, & Fraser, 2013). 4. R efer women who smoke to a smoking cessation program. Educate women to avoid secondhand smoke. 5. R efer women using cocaine and other substances for drug treatment. 6. E valuate personal/family resources and potential barriers to accessing care. 7. C onsult after the first prenatal visit regarding progesterone supplementation for the prevention of preterm delivery in women with a history of a prior b. H ypertensionc. R enal disease d. Aut oimmune disease (systemic lupus erythem-atous) 4. P regnancy history and personal habits this pregnancy a. M ultiple gestation b. P lacental abnormalities (placenta previa or abruption) c. P olyhydramnios or oliogohydramnios d. A bdominal surgery after 18 weeks gestation or cervical surgery e. V aginal bleeding in more than one trimester f. P regnancy the result of assisted reproductive technology (ART) g. P resence of a fetus with a congenital anomaly h. S hort interpregnancy interval of less than 6 months i. Body mass index (BMI) < 19/poor nutritional status j. S moking more than 10 cigarettes a day k. C ocaine use l. F ebrile illness/systemic infection m. H igh social stress n. O ccupational/ environmental exposures o. C ervical length on midtrimester ultrasound less than 25 mm 5. P resence of signs or symptoms of preterm labor a. U terine contractions that are frequently painless b. B ack pain—constant or intermittent c. M enstrual-type cramping d. P elvic pressure e. C hange in vaginal discharge f. V aginal spotting/bleeding (bloody show) B. Objective 1. P alpate abdomen/uterus for tenderness and place uterine contraction and fetal heart rate monitor 2. P erform speculum exam to obtain fetal fibronectin (f FN) specimen (this must be done before any digital exam of the cervix and other vaginal/cervical cultures) 3. C heck cervix for position, consistency, dilation, effacement (length), and station of presenting part III. a ssessment A. At risk for preterm labor B. Threatened preterm labor321 Plan
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v. Obs erve the woman for 1 to 2 hours and recheck her cervix. a. I f she meets the criteria for preterm labor, refer her to birthing unit for further evaluation with f FN swab that was obtained. b. Di agnostic criteria for preterm labor: i. Ge stational age 20-36 6/7 weeks AND ii. D ocumented regular contractions AND iii. One of the following: documented cervical change OR cervical dila-tion ≥ 2 cm OR cervical efface-ment ≥ 80%. c. I f no cervical change and no uterine contractions after a 2-hour observation, then educate regarding the signs and symptoms of preterm labor and criteria for calling the healthcare provider. re Feren Ce S Adams, M. M., Elam-Evans, L. D., Wilson, H. G., & Gilbertz, D. A. (2000). Rates of and factors associated with recurrence of preterm delivery. JAMA, 283, 1591-1596. American College of Obstetricians and Gynecologists. (2012). ACOG Practice Bulletin No. 130. Prediction and prevention of preterm birth. Obstetrics and Gynecology, 120, 964-973. Behrman, R., & Butler A. S. (Eds. ). (2007). Preterm birth: Causes, consequences, and prevention. Institute of Medicine Committee on Understanding Premature Birth and Assuring Healthy Outcomes. Washington, DC: National Academies Press. Bodnar, L. M., Klebanoff, M. A., Gernand, A. D., Platt, R. W., Parks, W. T, Catov, J. M., et al. (2014). Maternal vitamin D status and spontaneous preterm birth by placental histology in US Collaborative Perinatal Project. American Journal of Epidemiology, 178, 168-176. Iams, J. D. (2014). Prevention of preterm parturition. New England Journal of Medicine 370, 254-261. Khoury, J., Henriksen, T., Christophersen, B., & T onstad, S. (2005). Effect of a cholesterol-lowering diet on maternal, cord, and neonatal lipids, and pregnancy outcome: A randomized clinical trial. American Journal of Obstetrics and Gynecology, 193, 1292-1301. Martin, J. A., Hamilton, B. E., & Osterman, M. J. K. (2014). Births in the United States, 2013. (NCHS Data Briefs No. 175). Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention. Robinson, C. J., Wagner, C. L., Hollis, B. W., et al. (2013). Association of maternal vitamin D and placenta growth factor with the diagnosis of early onset severe preeclampsia. American Journal of Perinatology, 30(3), 167-72. Wei, S. Q., Qi, H. P., Luo, Z. C., & Fraser, W. D. (2013). Maternal vitamin D status and adverse pregnancy outcomes: A systematic review and meta-analysis. Journal of Maternal, Fetal, and Neonatal Medicine, 26, 889-899. s PTB in a singleton pregnancy (singleton live birth at 16 0/7-36 6/7 weeks gestation or stillbirth before 24 weeks) (ACOG, 2012; Iams, 2014). a. M easure transvaginal cervical length every 14  days from 16-24 weeks for high-risk women. If the cervical length is less than 30 mm increase to weekly. T ransvaginal cervical length less than 25 mm before 24 week of gestation: Cerclage should be considered especially if the patient had prior s PTB at less than 28 weeks or if membranes are seen. 8. C onsider a cervical length at the time of the second trimester ultrasound (anatomical survey) (18 to 20 weeks) in women without a history of preterm delivery. Consult if cervix less than 25 mm. Consider progesterone supplementation for the prevention of preterm delivery if cervical length less than 20 mm before 24 weeks (ACOG, 2012; Iams, 2014). B. Women with signs and symptoms of preterm labor (less than 37 weeks gestation) NOTE: Assessment depends on logistics of your practice site. Sites remote from a hospital or where transporta-tion issues are great may choose to monitor women over a period of time before referral to a hospital; more urban sites may refer directly. 1. Obt ain a clean catch urine and dipstick and send for urinalysis to rule out urinary tract infection. 2. P erform an abdominal exam for contractions and tenderness; use toco monitor to detect the presence of contractions. 3. A ssess fetal well-being with assessment of fetal heart tones. 4. D epending on setting: a. E ither refer to a birthing unit for further evaluation OR b. I f observation in the ambulatory setting: i. F irst, obtain a posterior fornix sample for fetal fibronectin (f FN). ii. Obt ain a sample for group B Streptococcus, if not previously obtained, and other samples, as indicated, for vaginal infections. iii. A ssess the status of placental membranes and presence of vaginal bleeding. If mem-branes are ruptured or bleeding is present, the woman should be referred immediately to the hospital. iv. The n, perform a digital cervical exam, if membranes intact and no bleeding and no placenta previa on ultrasound. 322 CHAPTER 35 | Preterm Labor Management
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d. D iabetes e. I mmunosuppression 2. R eproductive history a. Ge stational age b. Pa rity c. P yelonephritis in a prior pregnancy d. U rinary tract infection in prior pregnancy 3. P resence of signs or symptoms of cystitis a. A brupt onset of urinary frequency and hesitancy and dysuria b. S uprapubic or low back pain c. Fl ank pain (unusual) d. P resence of vaginal discharge or irritation (decreases the likelihood of cystitis) 4. P resence of signs of pyelonephritis a. S igns of cystitis PLUS/OR b. F ever (> 38° C) and chills c. N ausea and vomiting d. C ostovertebral tenderness e. Gr oss hematuria (not required) f. Di arrhea (rare) 5. P resence of signs or symptoms of preterm labor, e. g., contractions, low back pain, increased vaginal discharge, pelvic pressure B. Objective 1. F or diagnosis of ASB—culture urine on all pregnant women at 12-16 weeks or with initial prenatal visit if later (Lin, Fajarado, & U. S. Preventive Services T ask Force, 2008). 2. W omen presenting with UTI symptoms a. A ssess temperature, blood pressure, maternal pulse, and respiratory rate. Immediately refer women whose vital signs indicate possible pyelonephritis. b. Dips tick urine for nitrites, leukocytes, and blood c. L aboratory evidence of anemia (if anemic with pyelonephritis diagnosis, increased risk I. Intr oduction and general background A. Physiologic and anatomic changes of the urinary tract in pregnancy predispose lower urinary tract infections (UTIs) to ascend and become upper tract infections, i. e., pyelonephritis, which is a risk factor for preterm labor. B. Asymptomatic bacteriuria (ASB) is the presence of bacteria in the urine without symptoms and occurs in 2-9% of pregnant women (Nicolle et al., 2005). In pregnancy, 25-40% of women with untreated ASB will develop pyelonephritis; therefore, it is treated with antibiotics, unlike for nonpregnant women in whom it is left untreated. C. Maternal consequences from pyelonephritis in pregnancy can be life threatening and may include sepsis, acute respiratory distress syndrome, acute renal or heart failure, need for transfusion, and possibly death (Dotters-Katz, Heine, & Grotegut, 2013). II. Database (may include but is not limited to) A. Subjective 1. M edical history a. U rinary tract infection—number, precipitating factors, e. g., associated with coitus b. P yelonephritis c. U rinary tract abnormality, e. g., single kidney, displaced kidneys Mary Barger Ur Inary Trac T Infec TIon Preven TI on an D Manage M en T I n Pregnancy© Eliks/Shutterstock; © donatas1205/Shutterstock 32336Chapt Er
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D. Prevent recurrent infections and/or pyelonephritis: 1. Es tablish efficacy of treatment by repeat urine culture and sensitivity after treatment and each trimester of pregnancy. 2. P rescribe suppression for women with more than one UTI or pyelonephritis during pregnancy. E. Educate women with UTI regarding signs and symptoms of pyelonephritis v. Plan A. Women without ASB on initial culture do not need to be rescreened later in pregnancy unless they have a urinary tract anomaly or history of pyelonephritis. B. Women with ASB or acute cystitis 1. T reat with appropriate antibiotic for 3-7 days after initial C&S results available (Widmer, Gulmezoglu, Mignini, & Roganti, 2011). (See T able 36-1. ) 2. I f treating acute cystitis presumptively, follow up on urine culture results to ensure bacteria are sensitive to the prescribed antibiotic. If not, change to antimicrobial-sensitive agent. 3. R epeat urine C&S 1 week after treatment. of preterm birth—Dotters-Katz, Grotegut, & Heine, 2013) d. S end urine for culture and sensitivity (C&S) e. C heck for costovertebral angle (CVA) tenderness f. P alpate abdomen/uterus for tenderness and presence of contractions g. D epending on history, perform speculum exam to rule out urethritis from a vaginal infection h. C onsider vaginal exam if any suspicion of concomitant preterm labor signs III. a ssessment A. Asymptomatic bacteriuria B. Possible UTI C. Possible pyelonephritis Iv. g oals of c linical Management A. Identify patients at risk for UTI during pregnancy B. Diagnose both asymptomatic and symptomatic UTI C. Individualized treatment: Use medication that is sensitive, well tolerated, and low cost with the lowest number of treatment days and reduced daily dosing Table 36-1 Medications for Urinary Infections in Pregnancy Principles Contraindicated in pregnancy: fluoroquinolones and tetracyclines. Avoid in first trimester: nitrofurantoin and sulfonamides (ACOG Committee on Obstetric Practice, 2011; Crider et al., 2009) and trimethoprim (folic acid antagonist) because of increased birth defect risk. Avoid using sulfonamides and nitrofurantoin near time of birth because of theoretical increased risk of jaundice. Recommended treatment regimens, if microorganism susceptible Medication o ral Dose f requency per Day Duration in Days Indication a SB c ystitis Amoxacillin 500 mg Twice 3-7 x   Amoxacillin-clavulanate 500 mg Twice 3-7 x x Cefpodoxime 100 mg Twice 3-7   x Cephalexin 500 mg Twice 3-5 x   Fosfomycin 3 g Twice Once x x Nitrofurantoin 100 mg Twice 3-5 x x324 CHAPTER 36 | Urinary Tract Infection Prevention and Management in Pregnancy
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4. I f culture is positive, then re-treat for 7-10 days with antimicrobial sensitive agent. 5. R escreen each trimester or monthly. 6. I nitiate suppressive therapy for women with two or more urinary tract infections in pregnancy; typically nitrofurantoin 50-100 mg at bedtime; alternative is cephalexin 250-500 mg at bedtime. C. Women with suspected pyelonephritis 1. R efer to birthing unit for assessment and parenteral treatment. Most pregnant women with pyelonephritis will receive inpatient IV treatment until they are afebrile for at least 24 hours and then be discharged on a 14-day oral antibiotic course. They will also be monitored for premature labor. 2. R epeat urine C&S follow-up test of cure after 2-week antibiotic course is complete. 3. E nsure woman receives UTI suppressive therapy for remainder of the pregnancy. D. Women on suppressive therapy do not need monthly cultures but a repeat C&S in early third trimester (~ 32 weeks) to ensure adequacy of suppression. reference S ACOG Committee on Obstetric Practice. (2011). Committee opinion no. 494: Sulfonamides, nitrofurantoin, and risk of birth defects. Obstetrics and Gynecology, 117, 1484-1485. Crider, K. S., Cleves, M. A., Reefhuis, J., Berry, R. J., Hobbs, C. A., & Hu, D. J. (2009). Antibacterial medication use during pregnancy and risk of birth defects: National Birth Defect Prevention Study. Archives of Pediatric and Adolescent Medicine, 163, 978-985. Dotters-Katz, S. K., Grotegut, C. A., & Heine, R. P. (2013). The effects of anemia on pregnancy outcome in patients with pyelonephritis. Infectious Diseases in Obstetrics and Gynecology, 2013, 780960. Dotters-Katz, S. K., Heine, R. P., & Grotegut, C. A. (2013). Medical and infectious complications associated with pyelonephritis among pregnant women at delivery. Infectious Diseases in Obstetrics and Gynecology, 2013, 124102. Lin, K., Fajardo, K., & U. S. Preventive Services T ask Force. (2008). Screening for asymptomatic bacteriuria in adults: Evidence for the U. S. Preventive Services T ask Force reaffirmation recommendation statement. Annals of Internal Medicine, 149, W20-W24. Nicolle, L. E., Bradley, S., Colgan, R., Rice, J. C., Schaeffer, A., & Hooton, T. M. (2005). Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clinical Infectious Diseases, 40, 643-645. Widmer, M., Gulmezoglu, A. M., Mignini, L., & Roganti, A. (2011). Duration of asymptomatic bacteriuria during pregnancy. Cochrane Database of Systematic Reviews, 12, CD000491. 325 References
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Section V i ADUL t G e R onto L o GY H e ALt H MA inten A nce A n D PR o M otionjudgment to assess which preventive interventions are most appropriate for the patient. Despite strong evidence for effective and cost-effective preventive healthcare interventions, many of these measures remain underused among the U. S. population. A 2007 analysis by the National Commission on Prevention Priorities found that increasing the uptake of just five recommended prevention measures (aspirin to prevent heart disease, tobacco screening and intervention, colorectal cancer screening, influenza vaccination, and breast cancer screening) could save more than 100,000 lives in the United States each year (Partnership for Prevention, 2007). How, then, do we increase use of these services? The Community Preventive Services T ask Force, in collaboration with the CDC and the Agency for Healthcare Research and Quality, conducts systematic reviews and makes evidence-based recommendations for implementing programs and systems to improve the delivery of preventive health care. Examples of interventions that have been evaluated by the task force and recommended include client reminders, one-on-one education, and provider reminders for breast, cervical, and colon cancer screening. T ask force findings and recommendations can be found at their website, www . thecommunityguide. org. II. Individualizing scr eening decisions in the geriatric population A key concept in the care of older adults is the notion that decisions about screening for preventable illnesses need to be individualized rather than based solely on age. (see Figure 37-3) The large heterogeneity of comorbidities, life expectancy, and goals of treatment in this population means that decisions based simply on age could lead to both over-and undertreatment and potential harm. Screening adults whose life expectancy is shorter than the time it would take them to benefit from a screening intervention subjects them to the potential harms of screening without the potential I. Intr oduction and general background Health maintenance and promotion, also called preventive health care and healthcare maintenance, aim to prevent and minimize disease and promote health. Preventive healthcare interventions include counseling, immunizations, preven-tive medications (chemoprophylaxis), and screening. This chapter focuses on recommendations for adults for primary and secondary prevention, or measures to prevent disease and to detect asymptomatic conditions. It should be noted that older adolescents often receive care in adult clinic settings. For these patients, preventive service recommendations specific to adolescent populations may be more appropriate. These recommendations can be found in chapter of this book. The U. S. Preventive Services T ask Force (USPSTF), an independent group of national experts in prevention and evidence-based medicine, evaluates existing peer-reviewed evidence regarding preventive services. The task force then grades the quality of the evidence and makes recom-mendations based on these grades. These recommenda-tions, along with supporting resources for providers and patients, can be found at the website of the USPSTF, www. uspreventiveservicestaskforce. org. The Centers for Disease Control and Prevention (CDC) publishes immunization schedules based on recommendations of the Advisory Committee on Immunization Practices, a group of medical and public health experts. The 2015 Recommended Adult Immunization Schedule is included in Figure 37-1. The schedule is available in many formats from the CDC website, www. cdc. gov/vaccines/. See Figure 37-2 for guidance on scheduling pneumococcal vaccines. Many professional associations, such as the American Heart Association, the American Cancer Society, and the American Geriatrics Society (AGS), also make recommenda-tions for preventive health care specific to their areas of focus. These guidelines may conflict with each other and with the USPSTF recommendations. The provider must use clinical Helen R. Horvath and Hattie C. Grundland Adult He Alt H MAInten An Ce A nd P R o M ot I on© Eliks/Shutterstock; © donatas1205/Shutterstock 32637Chapt Er
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(Continues) Figure 37-1 Recommended Adult Immunization Schedule—United States—2016 Reproduced from U. S Department of Health and Human Services, Centers for Disease Control and Prevention. (2016). Recommended adult immunization schedule—United States—2016. Retrieved from http://www. cdc. gov/vaccines /schedules/downloads/adult/adult-combined-schedule. pdf 327 Individualizing screening decisions in the geriatric population
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Figure 37-1 Recommended Adult Immunization Schedule—United States—2016 (Continued) Reproduced from U. S Department of Health and Human Services, Centers for Disease Control and Prevention. (2016). Recommended adult immunization schedule—United States—2016. Retrieved from http://www. cdc. gov/vaccines /schedules/downloads/adult/adult-combined-schedule. pdf328 CHAPTER 37 | Adult Health Maintenance and Promotion
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Figure 37-1 Recommended Adult Immunization Schedule—United States—2016 (Continued) Reproduced from U. S Department of Health and Human Services, Centers for Disease Control and Prevention. (2016). Recommended adult immunization schedule—United States—2016. Retrieved from http://www. cdc. gov/vaccines /schedules/downloads/adult/adult-combined-schedule. pdf329 Individualizing screening decisions in the geriatric population
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Prognosis indices have been developed based on single dominant terminal conditions, such as dementia, cancer, heart failure, or coronary artery disease (Levy et al., 2006; Mitchell et al., 2010; Xie, Brayne, & Matthews, 2008). Other indices have been developed to address prognosis among older adults who do not have a dominant terminal illness. A systematic review of the literature for this population has led to the devel-opment of a web and mobile device calculator called e Prog-nosis (e Prognosis. ucsf. edu), which can help to estimate life expectancy (Y ourman et al., 2012). Along with age, this calcu-lator incorporates such factors as location of the patient (com-munity, skilled nursing facility, hospital), functional ability, and comorbidities to pair the clinical question with the appropriate index. As with other clinical decisions, one must assess whether the population studied is like the patient one is addressing. When considering screening, the provider should evaluate how long it would take the patient to benefit from the screen-ing. Time-to-benefit, or “lag time to benefit,” estimation seeks to answer the question, “When will it help?” Unfortunately, these data are rarely reported directly in clinical trials. Some current research is attempting to fill this gap. A 2013 meta-analysis found that the lag time to benefit for breast and colorectal cancer screening is 10 years (Lee, Boscardin, et al., 2013). T reatment for osteoporosis can be clinically significant at 1 year (Black et al., 2000; Pham, Datta, Weber, Walter,  & Colón-Emeric, 2011) and statin use for primary prevention of myocardial infarction (MI) is significant at benefits. Conversely, not screening an individual based on their age who would be expected to live long enough to benefit from the intervention would deny them the potential benefit of screening (Lee, Leipzig, & Walter, 2013). The dif-ficulty for the clinician arises when the time-to-benefit and the estimated life expectancy are similar and it is not clear whether potential harms or potential benefits are greater. In these cases, what can guide the clinician is the individual's values and preferences regarding healthcare interventions (Walter & Covinsky, 2001; Y ourman, Lee, Schonberg, Widera, & Smith, 2012). The following section provides the clinician with a framework for making clinical decisions about offering screening to older adults. Decision making about individualized screening requires three elements: (1) estimating the patient's life expectancy, (2) estimating the time-to-benefit of the proposed interven-tion or screening procedure, and (3) evaluating the patient's preferences around the potential harms and benefits of the intervention (Lee, Leipzig, & Walter, 2013). A core principle in geriatrics is that incorporating a person's comorbidities and functional status with their age can provide a more accurate picture of life expectancy than age alone (Walter & Covinsky, 2001; Y ourman et al., 2012). Those with fewer comorbidities and higher functional ability can be expected to live longer than the average, whereas those with more comorbidities and lower functional ability will have a shorter-than-average life expectancy. PCV-13 Schedule for all Adults Aged ≥65 Scenario 1: Pneumococcal vaccine naive Scenario 2: PPSV given since turning 65 Scenario 3: Prior PPSV but not given since turning 65 PPSV-23 6-12 months later but no sooner then 5 years from last PPSV-23PCV-13 ≥1 year since PPSV-23 ≥1 year since PPSV-23PCV-13 PCV-13PPSV-23 PPSV-23PPSV-23 6-12 months later Figure 37-2 Pneumococcal V accine Scheduling Reproduced from Black, C. L., Yue, X., Ball, S. W. et al (2014). Influenza vaccination coverage among healthcare personnel-United States, 2013-14 influenza season. Morbidity and Mortality Weekly Report, 63(37), 805-828. Retrieved from http://www. cdc. gov/mmwr/preview/mmwrhtml/mm6337a4. htm. 330 CHAPTER 37 | Adult Health Maintenance and Promotion
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2-5 years (Holmes et al., 2013). In older adults with diabetes, microvascular complications of diabetes are reduced only after 8 years of glycemic control, whereas treatment of hyper-tension and dyslipidemia shows benefits in 2-3 years (Brown, Mangione, Saliba, & Sarkisian, 2003). These timelines should be considered when deciding whether or not to screen a patient for one of these conditions. In addition to the potential benefits of screening inter-ventions, it is necessary to evaluate how a particular intervention fits with an individual's values, preferences, and goals of treatment. Harms to be considered include overdiagnosis (the identification and subsequent treatment of disease that would not have become clinically significant during the patient's lifetime), false positives leading to addi-tional diagnostic procedures with potential complications, and physical and psychologic discomfort from screening. Discussions of screening should include information on treatments that would be expected to follow a positive screening result. General treatment goals for a particular patient may include longevity, preserving function, comfort, or some combination of the three. Clarifying how a particular screening intervention fits within the patient's goals can help facilitate decision making. III. d atabase A. Subjective 1. S ymptoms that would trigger diagnosis/management rather than screening 2. R isk factors for diseases (see T able 37-1) that can be appropriately screened for: a. Be havioral characteristics b. P ast medical history c. F amily history Estimate life expectancy Consider comorbid conditions and functional impairment More comorbid conditions and greater impairment = shorter than average life expectancy* Fewer comorbid conditions and less functional impairment = greater than average life expectancy* *See Figure 37-5, Upper, middle, and lower quartiles of life expectancy for women and men at selected ages. OR Use appropriate calculator or index (examples: e Prognosis, Seattle Heart Failure Model) Estimate lag time to benefit for intervention Breast and colon cancer screening: 10 years (Lee, Boscardin, et al., 2013; Walter & Schonberg, 2014) Osteoporosis treatment: 1 year (Black et al., 2000) Hyperlipidemia treatment: 2-5 years (Holmes et al., 2013) Hypertension treatment: 1-2 years (Beckett et al., 2008; Musini, Tejani, Bassett, & Wright, 2009). Note higher threshold BP for treatment in older adults (James et al., 2013) Diabetes treatment: Prevention of microvascular complications with glucose control: approximately 8 years. Moderate glycemic control in the short term may improve wound healing, minimize symptoms of hyperglycemia, possibly maximize cognition (Brown et al., 2003) Note higher A1c threshold for older adults (Brown et al., 2003) Life expectancy greater than lag time to benefit: screening recommended Life expectancy and lag time to benefit are similar: patient values and preferences should be primary consideration in screening decision Life expectancy shorter than lag time to benefit: screening not recommended Figure 37-3 Individualizing Screening Decision Making for Older Adults Data from Lee, S. J., Leipzig, R. M., & Walter, L. C. (2013). Incorporating lag time to benefit into prevention decisions for older adults. JAMA, 310(24), 2609-2610. doi:10. 1001/jama. 2013. 282612331 Database
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Table 37-1 Risk Factors Related to USPSTF Screening Recommendations Risk Factor Consider Screening for: (see u SPS t F guidelines for greater detail) Smoking history Abdominal aortic aneurysm, coronary heart disease (cholesterol), lung cancer, osteoporosis Sexually active woman under 24 Chlamydia & gonorrhea New sex partner Chlamydia & gonorrhea Inconsistent use of barrier protection Chlamydia & gonorrhea, HIV History of sexually transmitted infections Chlamydia & gonorrhea Exchange of sex for drugs or money Chlamydia & gonorrhea, HIV, syphilis Men who have sex with men Hepatitis B virus (HBV), HIV, syphilis (also chlamydia & gonorrhea per CDC) Multiple sex partners Chlamydia & gonorrhea, HIV Past or present partner who is HIV+, IV drug user, bisexual HIV History of falls Fall risk Mobility problems Fall risk From country with high prevalence of HBV (all Asia, Africa, others—see USPSTF)HBV HIV+ HBV Household contact with HBV HBV IV drug use (past or present) HBV, HIV Transfusion before 1992 between 1978-1985Hepatitis C virus (HCV)HIV Hemodialysis, long-term HCV Incarceration HCV, syphilis Intranasal drug use HCV Unregulated tattoos HCV Born to HCV+ mother HCV Born between 1945 and 1965 HCV Diabetes Coronary heart disease (CHD) (cholesterol) History of CHD or noncoronary atherosclerosis CHD (cholesterol) Family history of CHD in men ≤ 50 and women ≤ 60 CHD (cholesterol) Hypertension CHD (cholesterol) Body mass index ≥ 30 CHD (cholesterol) History of fracture Osteoporosis Parent with history of hip fracture Osteoporosis History of glucocorticoid use for > 3 months Osteoporosis History of rheumatoid arthritis Osteoporosis Alcohol ≥ 3 units per day Osteoporosis Family history of breast, ovarian, tubal, peritoneal cancer Breast cancer (BRCA)Over 65 years and limited prior cervical cancer screening Cervical cancer Data from U. S. Department of Health and Human Services. (2014). The guide to clinical preventive services. Retrieved from http://www. ahrq. gov /clinic/pocketgd1011/gcp10s1. htm; U. S. Preventive Services Task Force (2014). About the USPSTF. Retrieved from www. uspreventiveservicestaskforce. org/Page/Name/about-the-uspstf. 332 CHAPTER 37 | Adult Health Maintenance and Promotion
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4. S creening for modifiable risk factors for disease (e. g., screening for hypertension, obesity, and hyperlipidemia as risk factors for cardiovascular disease) B. Secondary prevention—identify asymptomatic disease when treatment can stop it from progressing. Be sure to weigh risks and benefits of secondary prevention screening and anticipate management of positive screens before initiating screening. 1. S creening for cancer (e. g., mammogram for breast cancer, Pap smear for cervical cancer) 2. S creening for other conditions (e. g., depression, abdom-inal aortic aneurism, sexually transmitted infections) C. Tertiary prevention—interventions to minimize complications of disease once it is diagnosed. (Not addressed in this chapter—see chapters dedicated to particular conditions for prevention of disease-specific complications). VI. Plan A. Select and order appropriate screening, immunizations, chemoprophylaxis, and counseling based on risk. 1. U se evidence-based recommendations from USPSTF, CDC, or other appropriate source (see Figure 37-1, T able 37-2 and 37-3). 2. C onsider life expectancy and lag time to benefit of ntervention (see Figures 37-3 and 37-5). B. Consider and order health maintenance interventions related to previously diagnosed conditions (see Table 37-1) following evidence-based guidelines (USPSTF, 2014). C. Provide education and counseling as appropriate (see Box 37-1). VII. Self-management tools and resources for health professionals See USPSTF “Clinical Considerations” section for each recommendation for suggested tools and resources. See also T able 37-4. 3. F unctional status (as a contributor to life expectancy and ability to undergo screening/treatment) 4. Be havioral factors affecting ability to make healthy lifestyle changes 5. P atient values/preferences related to illness prevention and health care B. Objective 1. D emographics (age, gender) 2. I nitial screening physical exam assessments to consider: a. B lood pressure (USPSTF, 2014) b. Body mass index (USPSTF, 2014) c. C linical breast exam for women over 40 (Barton, Harris, & Fletcher, 1999) d. T imed-Up-and-Go or other balance/mobility exam for older adults (see Figure 37-4) (USPSTF, 2014) IV. Assessment A. Establish what currently undiagnosed conditions patient is at risk for based on subjective and objective characteristics. B. Consider patient's values, preferences, and stage of development related to recommended measures, particularly if life expectancy and lag time to benefit are similar. C. Evaluate patient's ability and desire to engage in recommended measures to prevent illness (see Box 37-1 ). V. Goals of clinical management A. Primary prevention—prevent injury and disease by minimizing risk factors. 1. C ounseling (e. g., behavioral counseling for those at risk for sexually transmitted infections) 2. I mmunizations (e. g., influenza, pneumococcal, human papilloma virus) 3. C hemoprophylaxis (e. g., aspirin for prevention of myocardial infarction and stroke)333 Self-management tools and resources for health professionals
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Older person encounters healthcare provider [A]Prevention of Falls in Older Persons Living in the Community Sidebar: Screening for Fall(s) Questions 1. Two or more falls in prior 12 months? 2. Presents with acute fall?3. Difficulty with walking or balance? 1. Obtain relavant medical history, physical examination, cognitive and functional assessment2. Determine multifactorial fall risk: a. History of falls b. Medications c. Gait, balance, and mobility d. Visual acuity e. Other neurological impairments f. Muscle strength g. Heart rate and rhythm h. Postural hypotension i. Feet and footware j. Environmental hazards [F]1 2 Screen for fall(s) or risk for falling (See questions in sidebar) [B] Yes No Yes Yes Yes Initiate multifactorial/multicomponent intervention to address identified risk(s) and prevent falls: 1. Minimize medications 2. Provide individually tailored exercise program3. Treat vision impairment (including cataract)4. Manage postural hypotension5. Manage heart rate and rhythm abnormalitis6. Supplement vitamin D7. Manage foot and footware problems8. Modify the home anvironment9. Provide education and information Answers positive to any of the screening questions? (See sidebar) [C] Does the person report a single fall in the past 12 months? [D]Evaluate gait and balance [G] Are abnormalities in gait or unsteadiness identified? Any indication for additional intervention? Reassess periodically No No No8 1093 45 67 Figure 37-4 Fall Prevention334 CHAPTER 37 | Adult Health Maintenance and Promotion
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Annotation A:  Older Adult Encounters with Healthcare Provider. This guideline algorithm is to be used in the clinical setting for assessment and intervention to reduce falls in community-residing older persons (≥65). The guideline algorithm is not intended to address fall injuries per se or falls that occur in the hospital. Annotation B:  Screen for Falls or Risk for Falling. The screening for falls and risk for falling is aimed at preventing or reducing fall risk. Any positive answer to the screening questions puts the person screened in a high-risk group that warrants further evaluation. All older adults who are under the care of a health professional (or their caregivers) should be asked at least once a year about falls, frequency of falling, and difficulties in gait or balance. Annotation C:  Screen Positive for Falls or Risk for Falling. Persons at higher risk of falling, identified by screening, should be assessed for known risk factors. A multifactorial fall risk assessment should be performed for community-dwelling older persons who report recurrent (≥2) falls, report difficulties with gait or balance, or seek medical attention or present to the emergency department because of a fall. Annotation D:  Report of a Single Fall in the Past 12 Months. A (first) single fall may indicate difficulties or unsteadi-ness in walking or standing. In older individuals, a fall may be a sign of problems in gait or balance that was not present in the past. Annotation E:  Evaluation of Gait and Balance. Gait and balance deficits should be evaluated in older individuals reporting a single fall as a screen for identifying individuals who may benefit from a multifactorial fall risk assess-ment. For persons who screen positive for falls or fall risk, evaluation of balance and gait should be part of the multifactorial fall risk assessment. Frequently used tests of gait or balance include the Get Up and Go Test; 9 Timed Up and Go Test,10 the Berg Balance Scale,11 and the Performance-Oriented Mobility Assessment. 5,12 Annotation F:  Determination of Multifactorial Fall Risk. A multifactorial fall risk assessment can reveal the factors that put an older adult at risk of falling and can help identify the most appropriate interventions. A multifactorial fall risk assessment followed by intervention to modify any identified risks is a highly effective strategy to reduce falls and the risk of falling in older persons. Reproduced from Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-157. doi:10. 1111/j. 1532-5415. 2010. 03234. x Figure 37-4 Fall Prevention. (Continued) Box 37-1 Assessing a P atient's Readiness for Behavior Change Counseling interventions regarding patient lifestyle and healthy behaviors begin with an assessment of the patient's recognition of unhealthy behavior and an assessment of the patient's readiness to make health-directed changes. Readiness to change is one of many frameworks designed to help the primary care provider choose an interviewing approach that will be most meaningful to the patient. The Transtheoretical Model defines behavior change as a pro-cess that occurs in stages. These stages, often referred to as “stages of change,” help the clinician understand why certain patients are more or less successful at changing behavior and which motivational interviewing strategies may help the patient move closer to changing unhealthy behaviors (Walley & Roll, 2007). Stage of Change Definition Patient Approach Precontemplation The patient has not recognized the behavior as unhealthy or the patient is not ready to change the behavior Inform and educate the patient about the unhealthy behavior and health consequences335 Self-management tools and resources for health professionals
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Stage of Change Definition Patient Approach Contemplation The patient understands his or her behavior is unhealthy but is ambiva-lent about making a change Elicit reasons for ambivalence W eigh the pros and cons and address the patient's concerns Individualized feedback on negative ef fects of the unhealthy behavior Preparation The patient makes a decision to change Commend the decision to change the behavior Action The patient is active in some change of the behavior Support the changes made and provide encour-agement to sustain the changes Maintenance The patient has made behavior change and is stable Recognize the patient' s commitment and contin-ued struggle to maintain the healthy behavior Anticipate dif ficulties that may challenge maintenance Address relapse Data from Prochaska, J. O., Norcross, J. C., & Diclemente, C. C. (1994). Changing for good. New York, NY: Avon Books; Walley, A. Y., & Roll, F. J. (2007). Principles of caring for alcohol and drug users. In T. E. King & M. B. Wheeler (Eds. ). Medical management of vulnerable and underserved patients: Principles, practice and populations (pp. 341-350). New York, NY: Mc Graw-Hill. Box 37-1 Assessing a P atient's Readiness for Behavior Change (Continued) Table 37-2 Chemoprophylaxis Recommended by USPSTF for Prevention Chemoprophylaxis Population Comments Aspirin Men 45-79 whose risk of MI is greater than risk of gastrointestinal (GI) bleed with aspirin. Women 55-79 whose risk of ischemic stroke is greater than risk of GI bleed with aspirin. This 2009 recommendation is in the process of being updated as of June 30, 2015. See USPSTF for details on comparing risks. USPSTF-recommended stroke risk calculator is not functional. Consider Framingham calculator. https://www. framinghamheartstudy. org/risk-functions/stroke/stroke. php Folic acid All women planning or capable of pregnancy should take a daily supplement containing 0. 4 to 0. 8 mg to prevent neural tube defects. This 2009 recommendation is in the process of being updated as of June 30, 2015. Breast cancer risk-reducing medications (tamoxifen, raloxifene)Women at increased risk of breast cancer Shared, informed decision making with consideration of risk for adverse effects of medication. Vitamin D Community-dwelling adults 65 years and older who are at increased risk for falls. The American Geriatrics Society (2011) recommends 800 IU daily. Data from U. S. Department of Health and Human Services. (2014). The guide to clinical preventive services. Retrieved from http://www . ahrq. gov/clinic/pocketgd1011/gcp10s1. htm; and U. S. Preventive Services Task Force (2014). About the USPSTF. Retrieved from www. uspreventiveservicestaskforce. org/Page/Name/about-the-uspstf; AGS. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-57. doi:10. 1111/j. 1532-5415. 2010. 03234. x. 336 CHAPTER 37 | Adult Health Maintenance and Promotion
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(continues)Table 37-3 USPSTF Screening and Counseling Recommendations Screening Recommendation Whom to Screen Screening test and Fr equency Additional Considerations and Counseling Recommendations Abdominal aortic aneurysm Men aged 65-75 who have ever smoked Ultrasonography One-time screening Smoking history of at least 100 cigarettes in lifetime Alcohol misuse All adults Many screening tools available (i. e., AUDIT, CAGE). Resources can be found at the USPSTF website and the National Institutes of Health Institute for Alcohol Abuse and Alcoholism website: www. niaaa. nih. gov/. The best interval for screening is unknown. Provide counseling for those with risky or hazardous drinking. See USPSTF website for resources. Risky/hazardous drinking: > 7 drinks/wk or > 3 drinks per occasion for women and > 14 drinks/wk or > 4 drinks per occasion for men BRCA risk assessment and genetic counseling/testing Women ≥ 18 years of age with ≥ 1 family member with breast, ovarian, or other types of BRCA-related cancer A number of risk assessment tools are available to help establish which women should be referred for genetic counseling (e. g., B-RST available at www. breastcancergenescreen. org). Consider periodic (every 5-10 years) review of family history to identify increased risk. Genetic counseling or BRCA mutation testing when access to health professionals trained to provide genetic counseling is available. Breast cancer Women aged 50-74 Mammography Every 2 years There is insufficient evidence to recommend for or against yearly clinical breast examination. Teaching breast self-examination is not recommended. Individualize screening decision for women > 74 and for those ≤ 74 with significant functional impairments and/or comorbidities (Lee, Leipzig, & Walter, 2013; Siu, 2016; Walter & Covinsky, 2001; Walter & Schonberg, 2014). Breast cancer risk Women ≥ 35 years without a prior diagnosis of breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS)If a family history of breast cancer or a personal history of breast biopsy, atypical hyperplasia or other nonmalignant high-risk breast lesions, or extremely dense breast tissue, consider further assessment with a breast cancer risk assessment tool such as the National Cancer Institute Breast Cancer Risk Assessment Tool (www. cancer. gov /bcrisktool/)If increased risk, provider should engage in shared, informed decision making regarding risk-reducing medication such as tamoxifen or raloxifene. See USPSTF website for resources. Cervical cancer Women aged 21-65 In women aged 21-65, screen with Pap smear every 3 years. For women 30-65 who desire longer intervals between screening, screen with a combination of Pap and human papillomavirus (HPV) test every 5 years. May discuss discontinuing screening in females > 65 if adequate recent screening was normal (i. e., 3 consecutive negative cytology results or 2 consecutive negative HPV results within 10 years before cessation of screening, with the most recent test occurring within 5 years) (Saslow et al., 2012). 337 Self-management tools and resources for health professionals
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Table 37-3 USPSTF Screening and Counseling Recommendations Screening Recommendation Whom to Screen Screening test and Fr equency Additional Considerations and Counseling Recommendations Chlamydia and gonorrhea infection Women ≤ 24 years of age who are sexually active and older women at increased risk CDC recommends screening for men who have sex with men (MSM) (Workowski & Berman, 2010)Nucleic acid amplification test (NAAT) (urine or vaginal or cervical swab for both) (CDC, 2014). For details on testing sites for MSM, see CDC info: www. cdc. gov/std/treatment/2010 /specialpops. htm, heading “MSM” (Workowski & Berman, 2010). Base screening frequency on individual risk. Risk factors include new or multiple sex partners, inconsistent condom use, history of sexually transmitted infections, exchange of sex for drugs or money. There is insufficient evidence to recommend routine screening for men. For MSM, see CDC info: www. cdc. gov /std/treatment/2010/specialpops. htm, heading “MSM” (Workowski & Berman, 2010). Colorectal cancer*Men and women 50-75 years of age Annual high-sensitivity fecal occult blood testing (FOBT) [guaiac-based FOBT or fecal immunochemistry test (FIT)] or sigmoidoscopy every 5 years combined with high-sensitivity FOBT every 3 years or colonoscopy every 10 years. Individualize screening decision for those > 75 years of age and for those < 75 years of age with significant functional impairments and/or comorbidities (Lee, Leipzig, & Walter, 2013; Walter & Covinsky, 2001). Depression* All adults if appropriate diagnosis, treatment, and follow-up can be offered Many screening tools available [e. g., Patient Health Questionnaire (PHQ)]. See USPSTF website for resources. The best interval for screening is unknown. Screening by asking two questions may be as effective as formal screening tools: “Over the past 2 weeks, have you felt down, depressed, or hopeless?” “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” Diabetes, type 2* All adults with sustained blood pressure > 135/80 (whether treated or untreated)Fasting plasma glucose, hemoglobin A1c, or 2-hour postload plasma glucose. The best interval for screening is unknown. Fasting plasma glucose has more reproducible results and is easier and faster to perform than other tests. The threshold for treating older adults for diabetes should be individualized. Reasonable A1c targets: 7. 0-7. 5% in healthy older adults with long life expectancy, 7. 5-8. 0% in those with moderate comorbidity and a life expec-tancy < 10 years, and 8. 0-9. 0% in those with multiple morbidities and shorter life expectancy (Kirkman et al., 2012). Fall risk Community-dwelling adults ≥ 65 years of age A prior fall and/or mobility problems in addition to a Timed Up-and-Go test. The best interval for screening is unknown. Consider annual screening in individuals at increased risk of falls. Risk factors include: age ≥ 65, history of falls, mobility problems, poor perfor-mance on the Timed Up-and-Go test. If at increased risk, refer to exercise and/or PT and supplement with vitamin D 800IU daily (American Geriatrics Society, 2011). See Figure 37-4. Hepatitis B virus (HBV)All adults at risk for HBVHepatitis B surface antigen (HBs Ag) Positive result indicates acute or chronic infection. Test for antibodies to HBs Ag (anti-HBs) and hepatitis B core antigen (anti-HBc) during screening to establish acute versus chronic infection. Use clinical judgement to establish screening interval. Increased risk includes those from countries with high prevalence of HBV infection (all Asia and Africa, others; see USPSTF website), HIV+ persons, injection drug users, men who have sex with men, and household contacts of individuals with HBV infection. (Continued)338 CHAPTER 37 | Adult Health Maintenance and Promotion
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Table 37-3 USPSTF Screening and Counseling Recommendations Screening Recommendation Whom to Screen Screening test and Fr equency Additional Considerations and Counseling Recommendations Hepatitis C All adults born between 1945-1965 and those at increased risk Hepatitis C antibody (HCab) One-time screen for those born between 1945-1965. Consider repeat screening for those with additional risk factors. Increased risk includes past or present IV drug use, transfusion before 1992, incarceration, intranasal drug use, unregulated tattoo(s), those born to an HCV+ mother. High blood pressure*All adults ≥ 18 years of age Sphygmomanometer measurement every 2 years if blood pressure ≤ 120/80 and annually if systolic 120-139 or diastolic 80-90Hypertension defined as blood pressure ≥ 140/90 found on 2 or more visits over a period of 1 to several weeks. In adults ≥ 60 years of age consider a target BP ≤ 150/90 (James et al., 2013). High cholesterol*All men ≥ 35 and 20-35 years of age if at increased risk for coronary heart disease (CHD). Women ≥ 20 years of age if at increased risk for CHD. Total cholesterol and high-density lipoprotein fasting or nonfasting. Screen every 5 years or with increased frequency if lipid levels close to levels requiring treatment; may decrease frequency of screening if repeated screening levels are normal. Increased risk for CHD: diabetes, prior history of CHD or noncoronary atherosclerosis, family history of CHD in men ≤ 50 and women ≤ 60 years of age, tobacco use, hypertension, and body mass index ≥ 30 HIV infection All adolescents and adults aged 15-65, > 65 if at increased risk Enzyme immune assay followed by confirmatory Western blot or immunofluorescent assay or rapid HIV antibody. The best interval for screening is unknown. Increased risk: those who have or request testing for other STIs; men who have sex with men; active IV drug users; multiple sex partners with inconsistent use of barrier methods; exchange of sex for drugs or money; past or present sex partner who is HIV+, bisexual, IV drug user; blood transfusion between 1978 and 1985. Intimate partner violence (IPV)Women of childbearing age There are several screening tools available such as the four-item HITS tool (Hurt, Insult, Threaten, Scream). See USPSTF website for resources. The best interval for screening is unknown. IPV describes physical, sexual, or psychologic harm by a current or former partner or spouse Lung cancer Adults aged 55-80 with a smoking history Low-dose computed tomography (LDCT) of the lung annually in current smokers aged 55-80 with a 30 pack-year-history or who have quit in the last 15 years. Discontinue screening in those who have not smoked for >15 years or in those with comorbidities that limit life expectancy or who would not want/tolerate treatment for lung cancer. Obesity and overweight All adults Body mass index (BMI) The best interval for screening is unknown. Obesity defined as BMI ≥ 30, overweight as BMI 25. 0-29. 9. Offer or refer overweight or obese adults who have additional risk factors for cardiovascular disease (hypertension, hyperlipidemia, diabetes, tobacco use) to intensive behavioral counseling about healthful diet and physical activity. Offer or refer obese patients to intensive, multicomponent behavioral interventions. (Continued) (continues)339 Self-management tools and resources for health professionals
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Table 37-3 USPSTF Screening and Counseling Recommendations Screening Recommendation Whom to Screen Screening test and Fr equency Additional Considerations and Counseling Recommendations Osteoporosis All women ≥ 65 years of age and younger women whose 10-year osteoporotic fracture risk ≥ 9. 3%. Dual-energy x-ray absorptiometry (DEXA) measured at the hip and lumbar spine. The best interval for screening is unknown. The Fracture Risk Assessment (FRAX) tool can be used to calculate an individual's 10-year risk for osteoporotic fracture (www. shef. ac. uk /FRAX/index. aspx). Note: In determining risk for women < 65, the bone mineral density field in the FRAX tool may be left empty. See instructions at tool web page. Sexually transmitted infection (STI) risk All adults Risk factors for STI: Multiple sexual partners History of STI within last year Adults at risk for STI should receive intensive behavioral counseling to prevent STI. See USPSTF website for resources. Skin cancer risk Adults ≤ 24 years of age Fair skin type as evaluated by eye and hair color, freckling, history of frequent sunburn. Those at increased risk should be counseled about minimizing exposure to ultraviolet radiation to prevent skin cancer. See USPSTF website for resources. Syphilis* Adults at increased risk Venereal Disease Research Laboratory (VDRL) or Rapid Plasma Reagin (RPR) The best interval for screening is unknown. Increased risk: men who have sex with men, those who engage in high-risk sex behavior, those who exchange sex for drugs or money, and adults in correctional facilities. Tobacco use* All adults Ask about tobacco use. Tobacco cessation interventions should be provided to those who use tobacco. Consider assessing readiness for behavior change (Figure 37-1). See USPSTF website for resources. * Update in progress as of July 2, 2015. Sources (unless otherwise noted): AGS. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-157. doi:10. 1111/j. 1532-5415. 2010. 03234. x; James, P. A, Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., et al. (2013). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 1097, 1-14. doi:10. 1001/jama. 2013. 284427; Kirkman, M. S., Briscoe, V. J., Clark, N., Florez, H., Haas, L. B., Halter, J. B., et al. (2012). Diabetes in older adults: A consensus report. Journal of the American Geriatrics Society, 60(12), 2342-2356. doi:10. 1111/jgs. 12035; Lee, S. J., Leipzig, R. M., & Walter, L. C. (2013). Incorporating lag time to benefit into prevention decisions for older adults. JAMA, 310(24), 2609-2610. doi:10. 1001 /jama. 2013. 282612; Saslow, D., Solomon, D., Lawson, H. W., Killackey, M., Kulasingam, S. L., Cain, J. M., et al. (2012). American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Journal of Lower Genital Tract Disease, 16(3), 175-204. doi:10. 1097 /LGT. 0b013e31824ca9d5; U. S. Department of Health and Human Services. (2014). The guide to clinical preventive services. Retrieved from www. ahrq. gov/clinic/pocketgd1011/gcp10s1. htm; U. S. Preventive Services Task Force. Published recommendations. Retrieved from www . uspreventiveservicestaskforce. org/Browse Rec/Index; Walter, L. C., & Covinsky, K. E. (2001). Cancer screening in elderly patients: A framework for individualized decision making. JAMA, 285(21), 2750-2756. Retrieved from www. ncbi. nlm. nih. gov/pubmed/11386931; Walter, L. C., & Schonberg, M. A. (2014). Screening mammography in older women: A review. JAMA, 311(13), 1336-1347. doi:10. 1001/jama. 2014. 2834; Workowski, K. A., & Berman, S. (2010). Sexually transmitted diseases treatment guidelines, 2010. MMWR. Recommendations and Reports, 59(RR-12), 1-110. (Continued)340 CHAPTER 37 | Adult Health Maintenance and Promotion
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Figure 37-5 Upper, Middle, and Lower Quartiles of Life Expectancy for Women and Men at Selected Ages Data from Walter, L. C., & Schonberg, M. A. (2014). Screening mammography in older women. JAMA: The Journal of the American Medical Association, 311(13), 1336-47. doi:10. 1001/jama. 2014. 283422. 0 17. 6 13. 4 9. 8 6. 8 4. 616. 6 12. 6 9. 1 6. 2 4. 0 2. 610. 3 7. 4 5. 0 3. 11. 91. 1 0. 05. 010. 015. 020. 025. 0 70 75 80 85 90 95Years Age Life Expectancy for Wo men 19. 4 15. 3 11. 5 8. 3 5. 8 4. 013. 9 10. 4 7. 4 5. 0 3. 32. 28. 0 5. 6 3. 8 2. 41. 51. 0 0. 05. 010. 015. 020. 025. 0 70 75 80 85 90 95Years Age Life Expectancy for Men Top 25th Percentile 50th Percentile Lowest 25th Percentile Top 25th Percentile 50th Percentile Lowest 25th Percentile341 Self-management tools and resources for health professionals
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Table 37-4 Self-Management T ools and Resources for Health Professionals Alcohol and substance use disorders prevention National Institutes of Health (NIH): National Institute on Alcohol Abuse and Alcoholism Resources for health professionals, including patient education materialsniaaa. nih. gov/publications/clinical-guides-and-manuals Centers for Disease Control and Intervention (CDC) Fact Sheets—Preventing Excessive Alcohol Use Resources for health professionalscdc. gov/alcohol/fact-sheets/prevention. htm Prevention of Substance Abuse and Mental Illness Substance Abuse and Mental Health Services Administration Resources for health professionalssamhsa. gov/prevention Drug Facts: Lessons from Prevention Research NIH: National Institute on Drug Abuse Resources for health professionalsdrugabuse. gov/publications/drugfacts/lessons-prevention-research Nutrition nutrition. gov U. S. Department of Agriculture (USDA) and other government agencies Practical information on nutrition, healthy eating, physical activity Resources for consumers, some Spanish Super Tracker USDAOnline physical activity and food/nutrition tracking site, free Resources for consumerssupertracker. usda. gov Occupational health CDC—Healthy Aging at Work Resources for consumers and health professionalscdc. gov/niosh/topics/healthyagingatwork CDC—Stress at Work Resources for health professionals, including patient education publications and videoscdc. gov/niosh/topics/stress CDC—Occupational Violence Resources for health professionalscdc. gov/niosh/topics/violence Physical activity Physical Activity Basics CDCResources for consumerscdc. gov/physicalactivity/everyone/guidelines/adults. html342 CHAPTER 37 | Adult Health Maintenance and Promotion
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Black, D. M., Thompson, D. E., Bauer, D. C., Ensrud, K., Musliner, T., Hochberg, M. C., et al. (2000). Fracture risk reduction with alendro-nate in women with osteoporosis: The Fracture Intervention T rial. FIT Research Group. Journal of Clinical Endocrinology and Metabolism, 85(11), 4118-4124. doi:10. 1210/jcem. 85. 11. 6953 Brown, A. F., Mangione, C. M., Saliba, D., & Sarkisian, C. A. (2003). Guidelines for improving the care of the older person with diabetes mellitus. Journal of the American Geriatrics Society, 51 (5 Suppl. Guidelines), S265-S280. doi:10. 1046/j. 1532-5415. 51. 5s. 1. x Centers for Disease Control and Prevention. (2014). Recommendations for the laboratory-based detection of chlamydia trachomatis and neisseria gonorrhoeae — 2014. Morbidity and Mortality Weekly Report, Re Fe Ren Ce S American Geriatrics Society. (2011). Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59(1), 148-157. doi:10. 1111/j. 1532-5415. 2010. 03234. x Barton, M. B., Harris, R., & Fletcher, S. W. (1999). Does this patient have breast cancer? JAMA, 282(13), 1270. doi:10. 1001/jama. 282. 13. 1270 Beckett, N. S., Peters, R., Fletcher, A. E., Staessen, J. A., Liu, L., Dumitrascu, D., et al. (2008). T reatment of hypertension in patients 80 years of age or older. New England Journal of Medicine, 358(18), 1887-1898. doi:10. 1056/NEJMoa0801369(Continued) Table 37-4 Self-Management T ools and Resources for Health Professionals Sexually transmitted infection prevention Sexually Transmitted Diseases (STDs): Prevention CDCResources for consumers Includes fact sheets on individual STIs in multiple languagescdc. gov/std/prevention Skin cancer prevention National Council on Skin Cancer Prevention Resources for consumers and health professionalsskincancerprevention. org CDC—Skin Cancer Resources for consumers and health professionals, including printable patient education materials in English and Spanish. cdc. gov/cancer/skin Suicide prevention Suicide Prevention National Institute of Mental Health Resources for consumers and health professionalsnimh. nih. gov/health/topics/suicide-prevention Tobacco use and cessation smokefree. gov espanol. smokefree. gov (Spanish) U. S. Department of Health and Human Services, NIH, National Cancer Institute, and USA. gov Resources for consumers and health professionals Five Major Steps to Intervention (The “5 As”) Agency for Health Research and Quality Resource for health professionalsahrq. gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/5steps. html Violence Prevention CDC Injury Prevention & Control: Division of Violence Prevention Resources for consumers and health professionals, including consumer fact sheets on topics including Understanding Intimate Partner Violence, Understanding Elder Abuse, Understanding Sexual Violence, Understanding Suicide cdc. gov/violenceprevention343 References
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63(2), 1-22. Retrieved at http://www. cdc. gov/mmwr/pdf/rr/rr6302 . pdf. Holmes, H. M., Min, L. C., Y ee, M., Varadhan, R., Basran, J., Dale, W., et al. (2013). Rationalizing prescribing for older patients with multimorbidity: Considering time to benefit. Drugs & Aging, 30(9), 655-666. doi:10. 1007/s40266-013-0095-7 James, P. A, Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., et al. (2013). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee ( JNC 8). JAMA, 1097, 1-14. doi:10. 1001/jama. 2013. 284427 Kirkman, M. S., Briscoe, V. J., Clark, N., Florez, H., Haas, L. B., Halter, J. B., et al. (2012). Diabetes in older adults: A consensus report. Journal of the American Geriatrics Society, 60(12), 2342-2356. doi:10. 1111 /jgs. 12035 Lee, S. J., Boscardin, W. J., Stijacic-Cenzer, I., Conell-Price, J., O'Brien, S., & Walter, L. C. (2013). Time lag to benefit after screening for breast and colorectal cancer: Meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ, 346, e8441. Lee, S. J., Leipzig, R. M., & Walter, L. C. (2013). Incorporating lag time to benefit into prevention decisions for older adults. JAMA, 310(24), 2609-2610. doi:10. 1001/jama. 2013. 282612 Levy, W. C., Mozaffarian, D., Linker, D. T., Sutradhar, S. C., Anker, S. D., Cropp, A. B., et al. (2006). The Seattle Heart Failure Model: Prediction of survival in heart failure. Circulation, 113(11), 1424-1433. doi:10. 1161 /CIRCULATIONAHA. 105. 584102 Mitchell, S. L., Miller, S. C., T eno, J. M., Kiely, D. K., Davis, R. B., & Shaffer, M. L. (2010). Prediction of 6-month survival of nursing home residents with advanced dementia using ADEPT vs hospice eligibility guidelines. JAMA, 304(17), 1929-1935. doi:10. 1001/jama. 2010. 1572 Musini, V. M., T ejani, A. M., Bassett, K., & Wright, J. M. (2009). Pharmacotherapy for hypertension in the elderly. Cochrane Database of Systematic Reviews, 4, CD000028. doi:10. 1002/14651858. CD000028 . pub2. Partnership for Prevention. (2007). Preventive care: A national profile on use, disparities, and health benefits. Retrieved from www. rwjf. org/content /dam/farm/reports/reports/2007/rwjf13325. Pham, A. N., Datta, S. K., Weber, T. J., Walter, L. C., & Colón-Emeric, C. S. (2011). Cost-effectiveness of oral bisphosphonates for osteoporosis at different ages and levels of life expectancy. Journal of the American Geriatrics Society, 59(9), 1642-1649. doi:10. 1111/j. 1532-5415. 2011. 03571. x Pilkinton, M. A., & T albot, H. K. (2015). Update on vaccination guidelines for older adults. Journal of the American Geriatrics Society, 63(3), 584-588. Prochaska, J. O., Norcross, J. C., & Diclemente, C. C. (1994). Changing for good. New Y ork, NY: Avon Books. Rapsomaniki, E., Shah, A., Perel, P., Denaxas, S., George, J., Nicholas, O., et al. (2014). Prognostic models for stable coronary artery disease based on electronic health record cohort of 102 023 patients. European Heart Journal, 35(13), 844-852. doi:10. 1093/eurheartj/eht533 Saslow, D., Solomon, D., Lawson, H. W., Killackey, M., Kulasingam, S. L., Cain, J. M., et al. (2012). American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. Journal of Lower Genital Tract Disease, 16(3), 175-204. doi:10. 1097/LGT. 0b013e31824ca9d5. Siu AL, on behalf of the U. S. Preventive Services T ask Force (2016). Screening for breast cancer: U. S. Preventive Services T ask Force recom-mendation statement. Ann Intern Med. doi:10. 7326/M15-2886. U. S. Department of Health and Human Services. (2014). The guide to clinical preventive services. Retrieved from www. ahrq. gov/clinic/pocketgd1011 /gcp10s1. htm. U. S. Preventive Services T ask Force (2014). About the USPSTF. Retrieved from www. uspreventiveservicestaskforce. org/Page/Name/about-the-uspstf. Walley, A. Y., & Roll, F. J. (2007). Principles of caring for alcohol and drug users. In T. E. King & M. B. Wheeler (Eds. ). Medical management of vulnerable and underserved patients: Principles, practice and populations (pp. 341-350). New Y ork: Mc Graw-Hill. Walter, L. C., & Covinsky, K. E. (2001). Cancer screening in elderly patients: A framework for individualized decision making. JAMAn, 285(21), 2750-2756. Walter, L. C., & Schonberg, M. A. (2014). Screening mammography in older women. JAMA, 311(13), 1336-1347. doi:10. 1001/jama. 2014. 2834 Workowski, K. A., & Berman, S. (2010). Sexually transmitted diseases treatment guidelines, 2010. MMWR. Recommendations and Reports, 59(RR-12), 1-110. Xie, J., Brayne, C., & Matthews, F. E. (2008). Survival times in people with dementia: Analysis from population based cohort study with 14 year follow-up. BMJ, 336(7638), 258-262. doi:10. 1136/bmj. 39433. 616678. 25 Y ourman, L. C., Lee, S. J., Schonberg, M. A., Widera, E. W., & Smith, A. K. (2012). Prognostic indices for older adults: A systematic review. JAMA, 307(2), 182-192. doi:10. 1001/jama. 2011. 1966344 CHAPTER 37 | Adult Health Maintenance and Promotion
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an increased incidence of respiratory, gastrointestinal, and musculoskeletal problems, it is imperative that the healthcare practitioner not focus solely on these conditions and perform routine screening for other chronic diseases as well as for secondary conditions that some patients with disabilities may be at increased risk of developing such as hearing loss, dental caries, and contractures. People with developmental disabilities have a higher preva-lence of chronic medical conditions such as epilepsy and neurologic disorders, dermatologic problems, fractures and orthopedic problems, gastrointestinal disorders, cardiovascular disorders, and mental health concerns. They are at risk for sec-ondary conditions such as pressure sores, constipation, and injuries. T o access healthcare services and manage their health, they may need support or accommodations for communica-tion, decision making, mobility, sensory processing, personal care, or behavior (Anderson et al., 2013). Currently, most adults with DDs live in the community in their own homes, with their families, or in group homes. Some lead very independent lives and others require a variety of services. Supports can include, but are not limited to, healthcare advocates, independent living coaches, vocational coaches, and case managers. They can also include personal assistants including direct support professionals, paid or unpaid family members, home health workers, and board and care home staff. T ransition of care from the child-oriented to an adult healthcare system is a particularly challenging and vulnerable time for patients, families, and clinicians. Clinicians who serve children have accumulated a wealth of information about the individual and often have a well-established, trusting relation-ship with the patient and the family or caregivers. Clinicians who serve adults are rarely trained in this field and often do not have the resources to provide the range of services required for comprehensive care. It is not uncommon for pediatric health-care providers to continue to provide care for individuals with DDs well beyond the age of 21 (American Academy of Pediatrics, American Academy of Family Physicians, & American College of Physicians, 2011; Kripke, 2014). I. Intr oduction and general background Individuals with developmental disabilities (DDs) experience health disparities across a number of domains. In the con-text of disability, a healthcare disparity is a population with a difference in health status not directly attributable to the con-dition leading to or associated with the disability. Disparities are caused in part by inadequate access to appropriate medical care, accommodations, services, and supports. They are com-pounded by intersectional issues with social determinants of health such as poverty, social exclusion, and implicit racial bias (Andresen et al., 2013; Horner-Johnson, Dobbertin, & Lee, 2013). The current healthcare system presents an array of structural deficits that severely limit its ability to provide appropriate care for this vulnerable population. These deficits include: Lack of clinicians who are knowledgeable and skilled in the treatment of adults with DDs Lack of regular health assessment and care Lack of coordination among provider teams Limited availability of services in places where patients with DDs live and reside Lack of access to health-related, long-term care services and supports Exclusion from research and proven care guidelines (Autistic Self Advocacy Network, 2014; Feldman, Bossett, Collet, & Burnham-Riosa, 2014) Life expectancy and quality of life have improved significantly over the past several decades as people with DDs moved from institutional settings to community-based care. The life expectancy of younger adults with DDs approaches that of the general population (Coppus, 2013). With the rise in life expectancy comes the increased risk for chronic diseases. Many of the chronic illnesses acquired by elders with DDs are similar  to those seen in the general population, such as cardiovascular disease, cancers, pulmonary disease, diabetes, and renal diseases. Although individuals with DDs do have Geraldine Collins-Bride and Clarissa Kripke Healt HCare Ma Intenan Ce for a dults w I t H d evelop M ental d I sa BI l I t I es© Eliks/Shutterstock; © donatas1205/Shutterstock 34538Chapt Er
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Developmental Disabilities, 2010, para. 1). Etiologies of ID include genetic conditions; intrauterine factors (asphyxia, maternal infections, and substance use); perinatal factors (hypoxic ischemic encephalopa-thy, sepsis, and prematurity); and postnatal causes, such as childhood infections, environmental toxins, trauma, and severe malnutrition. Alcohol exposure during pregnancy is the toxin most clearly linked to ID. Intellectual disabilities are complex neurodevelop-mental conditions that typically affect many areas of life function. The prevalence of ID is approximately 2% and covers a wide range of cognitive traits and charac-teristics. The majority of adults (80%) have mild ID. Regardless of functional ability, people with intel-lectual disabilities benefit from exposure to rich life experiences. Clinicians should presume competence, which means to assume that all people communicate and all people have the capacity to learn and grow and improve skills. It is important not to make assumptions about people's intellect when it cannot be accurately assessed because of limitations in expressive commu-nication. People with profound expressive communi-cation problems can have normal receptive language. Individuals with more severe functional limitations and communication challenges are at particular risk for not receiving regular preventive health screening and lifestyle counseling. Counseling, health educa-tion, and information should be delivered directly to patients and their supporters using plain language, pictures, or other visual supports and demonstrations regardless of whether the patient's understanding of the messages can be confirmed. Patients with intel-lectual disabilities often understand far more than is apparent from their facial expressions, body move-ments, or other responses. 2. C erebral palsy Cerebral palsy (CP) is a term used to describe a group of chronic conditions affecting body movement and muscle coordination. It is caused by differences in one or more specific areas of the brain, usually occurring during fetal development; before, during, or shortly after birth; or during infancy. Thus, these conditions are not caused by problems in the muscles or nerves. Instead, damage to motor areas in the brain affect the brain's ability to control movement and posture. The diagnosis of CP is not appropriate for individu-als with motor impairments caused by spinal cord injuries, peripheral nerve injuries, myopathies, or any other etiology that is not brain based. Historically, individuals with a physical exam consistent with CP were given the diagnosis only if the brain abnormali-ties or injuries occurred within the first 1-2 years of life—the period associated with the greatest amount A. Definition of DD The Developmental Disabilities Assistance and Civil Rights Act of 2000 defines DD as a severe, chronic disability caused by physical or mental impairments manifesting before the age of 22 that is expected to con-tinue indefinitely. These impairments cause limitations in three or more of the following categories: self-care, learning, receptive and expressive language, mobility, self-direction, capacity for independent living, and economic self-sufficiency (Developmental Disabilities Assistance and Bill of Rights Act, 2000). Many states define DD according to specific diagnoses or function and have differ-ent age cutoffs. T o receive Medicaid funding, states must have a mechanism of delivering supports and services to individuals meeting the state eligibility requirements for DD, although the structure of each system varies by state. Both federal and state statutes have been established to determine when an individual is eligible for services and supports. When a clinician is faced with a patient who has high support need, it is important to note that one cannot accurately separate individuals with intellectual disabil-ity (ID; defined as IQ less than 70 on a standardized IQ test) from those with borderline intelligence (IQ 70-85) or individuals with severe learning disabilities. Clinicians should be very careful about labelling a person as having ID without clear documentation and appropriate testing. Clinicians can refer individuals to the local or regional developmental resource center for an eligibility consul-tation or determination of changes to their individual program plan as their needs evolve. There is a strong self-advocacy movement and the dis-ability rights community has fought hard to dispel the old notion that individuals with disabilities are limited in their capacity to contribute meaningfully and be fully included in society. People with disabilities have the same rights to lead productive, independent lives as other citizens, and communities benefit from diversity including having peo-ple with developmental disabilities integrated into school, work, religious, and social organizations. The Americans with Disabilities Act guarantees people with disabilities the right to access healthcare services although many phys-ical, financial, and programmatic barriers still exist. B. Overview of common syndromes seen in primary care 1. I ntellectual disability (ID) (formerly mental retarda-tion) ID is a “disability characterized by significant limi-tations both in intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior, which covers a range of everyday social and practi-cal skills. This disability originates before the age of 18” (American Association on Intellectual and 346 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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and controlling their bodies (Yin Foo, Guppy, & Johnston, 2013). Performing clinical interviews with nonverbal patients requires special techniques or adaptive equipment. For video models of appro-priate interview techniques, visit https://www. mededportal. org/icollaborative/resource/904. The impairments that result from CP may “become more disabling as the person ages or they may accelerate the aging process” (Svien, Berg, & Stephenson, 2008). Symptoms of fatigue, depression, impaired mobil-ity, and musculoskeletal problems frequently worsen with aging. Individuals with CP have high rates of cardiovascular and respiratory disease with aspiration pneumonia as the leading cause of death across all age groups (Frisch & Msall, 2013; Svien et al., 2008). 3. Aut ism spectrum disorders Autism spectrum disorders (ASDs) are heteroge-neous neurodevelopmental conditions of unclear etiology that are classified according to the Diagnostic and Statistical Manual 5 (DSM-5) criteria to include atypical development in two major areas: (1) commu-nication used for social purposes, and (2) restricted, repetitive patterns of interests, behaviors, or activi-ties. The hallmark of ASDs is atypical social interac-tion, resulting from sensory-motor or movement differences or problems with language or social under-standing. In addition, current DSM-5 criteria require deficits in the use of nonverbal communication (e. g., quality of eye contact, use of gestures, odd facial expressions, misreading other people's facial expres-sions, tone of voice) and difficulties with establishing meaningful relationships with peers. Other criteria include a series of highly focused interests over their lifetime that are either unusual or highly focused, need for routines and rituals and distress with change, and repetitive motor mannerisms (hand-flapping, finger flicking, or shuddering, occurring most often when the individual is happy or distressed). Although it has long been recognized that people with ASD react in atypical ways to various sensory input, ranging from extreme negative reactions to sounds, smells, or touch to fascination or soothing related to sounds, visual stimuli, or movement, it was not until the publication of the DSM-5 that sensory issues were included in the diagnostic criteria for ASDs. It is extremely important for the clinician to understand the particular sensory issues that the individual with autism experiences in order to deliver good care. People on the autism spectrum have a wide range of strengths and challenges, which is one of the reasons that the condition is considered to be a spectrum. Language skills range from nonverbal to normal or advanced language skills. However, even individuals of brain development. The time frame for applying the CP diagnosis has loosened over the last several years because of the recognition that the brain con-tinues to develop throughout childhood. Children with brain damage secondary to central nervous sys-tem infections or nonaccidental or accidental trauma that causes motor impairments meet criteria for a CP diagnosis, even if the injury occurs after 2 years of age. There is no longer an exact age cutoff for applying the diagnosis; clinical judgment is used to identify children with clear brain-related motor limitations “Cerebral” refers to the brain and “palsy” to muscle weakness and difficulty with control. Because people may not be able to voluntarily control muscles, this can have an impact on the ability to speak, gesture, or type. Cerebral palsy itself is not progressive (i. e., brain changes do not evolve); however, secondary conditions such as muscle spasticity can develop, which may get better over time, get worse, or remain the same. Cerebral palsy is not communicable. It is not a disease and should not be referred to as such. Although cerebral palsy is not “curable” in the accepted sense, training, therapy, adaptive equipment, and an accommodating physical and social environ-ment and access to education, employment, and services can greatly improve function and quality of life (United Cerebral Palsy, 2011). The prevalence of CP is 2. 1-3. 3 per 1,000 live births with higher rates seen in males and African Americans (Y eargin-Allsopp, 2010). The greatest risk factor for CP is prematurity. An estimated one in three very-low-birth-weight children (< 1,500  g) are eventually diagnosed with CP. CP occurs as a consequence of the perinatal course. Spastic diplegia (greater involvement in the legs than the arms) is the type of CP most commonly associated with prema-turity with hallmark findings of periventricular leu-komalacia commonly seen on CT. Hemiplegic (one side of the body) CP is almost always caused by an in-utero or perinatal stroke, which should raise concerns about possible familial hypercoagulable disorders. Other etiologies for CP include chromosomal and brain anomalies, genetic and metabolic conditions, infection, and trauma. Individuals with CP frequently have problems with spasticity, seizures, mobility, dystonia, dysar-thria, swallowing, constipation, and gastroesopha-geal reflux (Peterson, 2013). People with cerebral palsy have a wide range of intellect so it is important not to make assumptions about people's intellect based on their method of expressive communica-tion. Many people with CP have normal intelligence, even if they have difficulty producing clear speech 347 Introduction and general background
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with average to advanced expressive and receptive language skills may demonstrate deficits in how to use language for social purposes (referred to as “prag-matic” language). Problems with motor planning and coordination, sometimes affecting speech, are increasingly being recognized in persons with ASDs. Some people on the autism spectrum are highly verbal or skilled in writing and mechanical skills. Some have challenges with communication and motor skills including difficulty with articulation and controlling and coordinating movements. Sensory processing differences combined with com-munication and motor planning problems and lack of accommodation and understanding can lead to difficulties with social interaction, misinterpreted behavior, and developing friendships and peer rela-tionships. They can also lead to the behaviors seen in ASD as described previously or regulating “stims” (self-stimulating behaviors), narrow focus on specific interests or activities, and difficulties with changes to routine, environments, or transitions The prevalence of people diagnosed with ASD continues to rise but how much of the increase can be attributed to changes in diagnostic criteria, access to services, and reclassification of individuals with other DDs continues to be a subject of debate. Most studies show that somewhere between 30% and70% of the increase is due to the aforementioned issues. However, that leaves at least 30% of the increased incidence of ASDs that may be attributed to a true increase in the condition. ASDs are diagnosed in boys four times more fre-quently than girls. The incidence of intellectual impair-ment is much lower than previously estimated once appropriate testing is done. Many individuals with ASD experience sensory integration problems and may be extremely sensitive to sounds or stimuli in the environment. Sensory processing differences should be explored to learn how to increase the comfort of people with autism in medical environments and during the physical examination. Many people with autism also have seizure disorders and associated men-tal health conditions. Anxiety almost always accom-panies ASDs with depression being quite common as the individual approaches the teenage and adult years. Although individuals with ASD may experi-ence the same range of health problems as the general population, the communication and behavioral fea-tures of this condition often require accommodations to deliver high-quality care in primary care settings. These accommodations might include preparation about the visit or examination ahead of time and the use of a timer to indicate the start and stop of the examination (Nicolaidis, Kripke, & Raymaker, 2014). 4. Ge netic disorders A comprehensive genetics work-up, including a microarray test that looks at the entire genome for duplications and deletions, can reveal the causes of DD in many individuals (estimates range from roughly 30% to 60%). One of the most common and well characterized of these genetic conditions is Down syndrome, a chromosomal disorder with an estimated incidence of 1 in 691. The risk for Down syndrome rises with increasing maternal age (Parker et al., 2010). The distinguishing characteristics of Down syndrome include facial dysmorphology (dysmorphic indicates an abnormal appearance), muscle hypotonia, and ID of varying degrees. Numerous medical problems are seen with Down syndrome including visual and hearing impairments, obesity, sleep apnea, hypothyroidism, cardiac and respiratory diseases, and early-onset Alzheimer disease. There are healthcare guidelines for following individuals with Down syndrome (Ross & Olsen, 2014; Sullivan et al., 2011). When genetic syndromes are suspected or the etiology of a developmental disability is unclear, referral to genetics can be helpful. Given the advances in today's genetic testing, it may be helpful to refer adults with unidentified ID for a genetics evaluation for further diagnostic testing. References for learn-ing about other common (fragile X and Klinefelter syndromes) and less common genetic syndromes can be found at the end of this chapter. 5. E pilepsy Epilepsy refers to a group of conditions that are characterized by the recurrent disturbance of cere-bral function (seizures) caused by excessive neuronal discharges in the brain occurring in a paroxysmal manner. An epileptic seizure occurs when the cere-bral cortex is rendered hyperexcitable (because of an increase in excitatory neurotransmission, a decrease in inhibitory neurotransmission, or a disturbance in brain circuitry) by any of a number of causes including metabolic disturbances, injuries, strokes, tumors, and developmental abnormalities. For further discussion of epilepsy, see Chapter 55. II. d atabase (may include but is not limited to) A. Subjective It can be challenging to obtain an accurate and compre-hensive history on individuals with DDs, especially when the individual has communication or cognitive impair-ments. In order to gather a comprehensive and accurate 348 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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b. P revious medical illnesses, noting history of i. E pilepsy: frequency of seizures, medica-tions, use of seizure tracking logs, and emer-gency management plan. ii. G astroesophageal reflux disease: previous work-up, treatment, and Helicobacter pylori testing. iii. C onstipation: unrecognized or untreated constipation can be a significant cause of morbidity and mortality. Note previous work-up and treatment. iv. V isual impairment: use of eyeglasses or con-tact lenses and date of last ophthalmology examination. v. H earing impairment: use of hearing devices and date of last audiology examination. vi. S ensory perceptual differences: note processing of sounds, touch, taste, and sensation, which may affect the physi-cal examination or interpretation of pain behavior. Document recommendations from patients, caregivers, family, and others about accommodations, strategies and the best methods of approaching individuals with sensory integration differences. c. C ommunication: document the patient's usual method of communication (verbal, written, sign language, behaviors, or gestures) and use of aug-mentative devices. d. M obility and neuromotor function: note if the patient is ambulatory or nonambulatory, use of adaptive equipment, and how much time per day is spent using the equipment. Note how the person transfers if non-weight bearing and what assistance is needed for transfers (equipment, such as a Hoyer lift; staff or family and how many are needed). Note fine and gross motor skills, spasticity, and changes in motor tone, either increased or decreased. e. S wallowing and feeding: episodes of choking or coughing with eating, history of aspiration, pneumonia, last swallowing study, and speech therapy treatments. f. Bo wel and bladder function: constipation, uri-nary incontinence or retention, and use of dia-pers or other incontinence supplies. g. D ental health issues: caries, periodontal disease, and gingival hyperplasia. Identification of risk factors for dental disease is important to avoid effects of premature demineralization. Often, patients have undiagnosed conditions of gas-tric reflux resulting in dental erosion or medi-cation induced xerostomia, which leaves the oral cavity hyperacidic and prone to premature understanding of the patient, start by collecting infor-mation directly from the patient. Historical data can be obtained from a variety of sources including caregivers, case managers, ID and DD nurses, and medical record review. In some systems, a structured health interview and examination tool is being used to collect and document important past and current health issues. An example of such a tool can be found at www. cddh. monash. org /disability-health-assessment. html. This yearly health assessment form is a component of many healthcare delivery models for adults with DDs throughout the world, although not consistently in use in the United States. These health assessment forms have been well studied and capture key information on functional, behav-ioral, developmental, and psychosocial issues pertinent to adults with DDs (Robertson, Hatton, Emerson, & Baines, 2014). Regardless of the type of data collection tool used for the history and physical examination, when possible, the healthcare provider should allow extra time for appointments when seeing individuals with DDs. It can also be helpful to schedule visits at regular or more  frequent intervals to address the complexities of the patient's healthcare issues. Flexibility and creativity are often required to ensure a successful office visit. Home visits or visits in community settings can be very effective ways to provide care. Such strategies as desen-sitization, telephone conferences with caregivers, and obtaining assistance from health advocates or case manag-ers can allow the visit to proceed more smoothly. Always attempt to prepare the individual for the appointment and enlist support from a trusted caregiver. For severely agitated patients, sedation with a low dose of benzodiaz-epines, such as lorazepam, 0. 5-1 mg, may be indicated. A test dose of the medication can be tried at home first to determine the timing of peak effect and dose and because some patients have been known to experience a paradoxi-cal reaction where agitation actually increases rather than decreases. Multidisciplinary telemedicine consultation has been shown to be an effective option for addressing difficult behavioral, medical and psychiatric issues in some patients with complex DD disorders www. uctv/show /telemdicine-assessment-and-Consultation-T eam-TACT-Caring-for-Individuals-with-Complex-Developmental Disabilities-in-Rural-Northern-California-28909. 1. P ertinent past medical history, as outlined in Chapter 37 (Adult Health Maintenance and Promotion), with a focus on the following additional data a. E tiology of DD with review of pediatric records and medical summary when possible. Note previous developmental and genetic evalua-tions (Sullivan et al., 2011). Note any history of institutionalizations. 349 Database
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demineralization. Checking for adequate and healthy saliva can help minimize effects of dental disease. Prevention strategies of neutralizing the acids in the mouth through sodium bicarbonate rinses, increasing hydration, and possible fluoride varnishes or sealants (Marinho et al., 2013) can prevent dental caries. Inquire about ongoing dental care, cleanings, and need for sedation before dental visits. h. M ental health issues: depression, posttraumatic stress disorder, and anxiety are the most com-mon disorders with rates similar to the general population. There is a much lower incidence of psychotic disorders, although antipsychotic medication is often overprescribed to con-trol behavior. Ask specifically how symptoms manifest themselves. Some patients may be capable of verbally expressing mood symptoms and others may express symptoms as a change in behavior. Behavior needs to be interpreted developmentally. For example, a person with an intellectual disability may have imaginary friends and tantrums when frustrated. This behavior is appropriate to the person's intellectual develop-ment and is not an indication of a mental illness. i. M edications: polypharmacy is a significant issue, with multiple medications often used to treat the same health problem. This is an especially com-mon, ineffective and harmful practice used in the treatment of aggressive or other problem behav-iors. It is important to note the indications and duration of use for all medications with attention to any side effects, drug interactions, and medi-cation efficacy. j. I mmunization status: in addition to the primary vaccination series and scheduled boosters, note if the patient has received vaccines for hepatitis A and B, pneumococcal, and seasonal flu. k. H istory of injuries or falls l. H istory of abuse or victimization. This is espe-cially prevalent in those individuals with IDs but it is also seen with high frequency in all individ-uals with disabilities (Sobsey & Doe, 1991). m. H istory of resistive or challenging behavior. Behavior is often a form of communication but can easily be misinterpreted, especially in disabilities that affect sensory processing and movement. Difficult behaviors are not part of the disabil-ity but rather a means of communication for a patient with neurocognitive disorders. Difficult behaviors that are new or a change from the indi-vidual's usual level of functioning may signify an undiagnosed medical or psychiatric problem or may be a sign of a mismatch between a person's needs and the services and supports they are receiving or the environments in which they live and work. New behaviors always warrant a medical evaluation. Additionally, new behaviors or significant change in behaviors can indicate the individual has experienced abuse or neglect; therefore, assessment specific to this is also important. Note previous medical and psychi-atric evaluations of behavior change. Document behavioral, environmental, and pharmacologic therapies used for treatment. 2. F amily history, with emphasis on developmental and genetic disorders 3. O ccupational history: people with DDs work in a variety of settings. Inquire about a job coach or other personnel support present at work. Obtain specific details about job tasks to screen for repetitive motion injuries. Ask about job satisfaction and relationships with coworkers. 4. P ersonal and social history a. H ousing status and supports: note if the patient lives independently and what support is required for independent living, such as in-home support services, independent living coaches, or case management support. Include type of housing (apartment, family, or residential group home), noting how many individuals live in the home and ratio of staff/caregivers needed to provide a safe environment. b. R elationships and social support network: note significant relationships with family, friends, sexual and life partners. Inquire about the quantity and quality of social contact and relationships. c. F uture goals: note desired future personal, educational, and occupational goals. 5. H abits a. N utrition b. E xercise and activity c. T obacco, alcohol, and substance use d. Sl eep e. S exual activity 6. I nterdisciplinary healthcare team members: note each team member's name and contact information, which may include a case manager, nurse, dentist, behavior specialist, pharmacist, physical therapist, occupational therapist, speech and language therapist, psychotherapist, and medical specialists (Figure 38-1). B. Objective 1. P erform an annual physical examination with blood pressure, height, weight, and body mass index (Sullivan et al., 2011). The physical examination is 350 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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III. a ssessment A. Identify the patient's general and specific health risk profile. If the cause of the DD is unknown or unclear, consider a referral to genetics for an evaluation (Sullivan et al., 2011). B. Recognize health habits that benefit from lifestyle modification. C. Ascertain additional members of the interdisciplinary health team that would be beneficial to improve the healthcare plan (Figure 38-1). D. Determine the support needed for medical decision making and informed consent for particularly important for patients with cognitive and communication impairments, where subjective symptoms may be difficult to elicit (Figure 38-2). 2. P ay particular attention to a careful oral examination given the frequency of dental disease (National Institute of Dental and Craniofacial Research, 2009; Sullivan et al., 2011). 3. P erform annual office-based vision and hearing screening examinations (Sullivan et al., 2011). 4. D ocument the patient's baseline, typical behavior, and method of communication. 5. S chedule a separate appointment dedicated solely to the gynecologic examination. Extra time is needed for the pelvic examination because these examinations can be challenging for providers and for women with disabilities (Figure 38-3). Oversight agencies Regional center case coordinator Name: Telephone: Vocational rehab/Education counselor Name: Telephone: Agency: Day program coordinator Name: Telephone: Agency: Other case coordinator(s) Name: Telephone: Agency: Name: Telephone: Agency: Name: Telephone: Agency:Power of attorney or conservator Name : Telephone: Patient Name : Telephone: Health advocate Alternate advocat e Name : Telephone: Primary group home, residential or family caregiver Direct caregiver(s) Name : Telephone:Primary care site Name :Interdisciplinary healthcare team chart Name : Telephone: Name : Telephone:Name : Telephone:Primary care physician / Nurse practitioner Telephone:Name : Primary contact: Nurse Telephone:Name : Primary contact: Dentist Telephone:Name : Primary contact: Durable Medical Equipment Provider(s) Name : Telephone: Name : Telephone:Pharmacist Name : Telephone: Figure 38-1 Interdisciplinary Healthcare T eam Chart Reproduced from Office of Developmental Primary Care, University of California, San Francisco. http://odpc. ucsf. edu. 351 Assessment
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diagnostic testing and procedures. Document whether the individual has a power of attorney or a legal decision maker for healthcare decisions. Although many individuals with IDs and DDs require the support of families and caregivers for decision making, it is important to remember that people with IDs and DDs have the right to make decisions about their lives and their health care. For individuals who lack capacity for decision making even with support and have no identified power of attorney for health care, the state developmental disability service can be contacted for procedures to support medical decision making for diagnostic, treatment, or emergency decisions. E. Assess the patient and caregiver's assets, barriers, and resources needed for implementing recommendations. Iv. p lan A. Diagnostics (screening and secondary prevention tests) 1. S creen for diseases and conditions based on the patient's risk profile. 2. S creen for diseases and conditions specific to the patient's underlying DD or known specific developmental syndrome. For specific screening and diagnostic test recommendations see T able 38-1. f IGure 38-2 e xam r oom e tiquette You may need to provide support to communicate with a patient with a developmental disability. Communication may take more thought and planning. Assess whether your patient uses spoken language; if not, he or she may use other forms of language, such as sign language, written language, or augmentative and alternative communication. Even people who do not use language can communicate through behavior, facial expressions, and sounds. Listening to your patient may require using more of your senses. The following are some ideas, but ask your patient and caregivers what works best for them. Order an interpreter if spoken English is not the patient's primary language. Use person-first or identity-first language for the autistic, deaf, and blind communities (unless your patient prefers something else). T alk directly to your patient in an adult voice and listen attentively for your patient to respond and to finish. If your patient appears to be thinking, wait quietly. A patient may have better receptive than expressive language. Use plain language without jargon. If your patient is not using words to communicate, then try nonverbal communication strategies, such as demonstrations, pictures, touch, gestures, and facial expressions. Get your patient' s attention before speaking to him or her. Check for understanding by repeating and asking your patient to repeat. If necessary, use short, concrete questions that require yes or no answers. If necessary, ask questions that can be answered nonverbally. For example, “Show me how you say yes. ” Sit at eye level and treat wheelchairs as personal space. Don't touch a wheelchair without permission. Before helping, offer assistance, and wait for a response and instructions. Offer to shake hands even if your patient has limited use of hands or an artificial limb. Identify yourself and others to people with visual disabilities and indicate to whom you are speaking. It is okay to use common idioms that refer to vision or hearing such as, “Have you heard about... ” or “See the light... ” Used with permission from the Office of Developmental Primary Care, Department of Family & Community Medicine, University of California, San Francisco. 352 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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syndrome, CP, Prader-Willi syndrome, history of frac-tures, history of amenorrhea, and cigarette smoking). 5. F or mental health: review common stress management strategies with patients and caregivers (Hwang & Kearney, 2013). Prompt referral for psychologic counseling or psychiatry for signs and symptoms of mental illness. 6. F or oral health: to reduce dental caries and gingival disease an expert dental panel recommends: a. B rushing teeth twice daily for 2 minutes with a fluoridated toothpaste containing triclosan. b. U sing xylitol for 5 minutes, three times per day. If the patient tolerates chewing, use chewing gum. If chewing is not possible, use a dissolved lozenge, spray, mint, or lollipop. B. Treatment 1. F or general health guidelines, see Chapter 37, Adult Health Maintenance and Promotion. 2. F or recommendations targeted toward individuals with DDs, see T able 38-1. 3. F or immunizations: see the Centers for Disease Control and Prevention Recommended Adult Immunization Schedule at www. cdc. gov/vaccines /schedules/index. html. 4. F or bone health: advise adequate calcium (1,500 mg per day) and vitamin D (400-800 IU per day) supple-mentation for those patients with a high-risk profile for osteoporosis (mobility impairments, long-term use of antiepileptic or antipsychotic medications, Down f IGure 38-3 tips for a s uccessful pelvic e xam For some women with disabilities, pelvic exams can be frightening and potentially uncomfortable. If the situation permits, focus the first visit on history and relationship building alone. The following may be helpful to reduce both the patient's and the provider's anxiety about the pelvic examination: Get to know your patient before attempting a pelvic exam. Educate the patient and caregivers about the exam. Don' t assume that a pelvic exam will be any more difficult or uncomfortable for a person with a disability than for anyone else. You don't know until you try. Women with disabilities, including those with intellectual disabilities, can and do have sex. Use anatomy models with visual demonstration before the visit. Allow extra time (this is a must!). Encourage your patient to bring a supportive person to the appointment. If needed, locate the cervix manually. The anatomy of women with disabilities is often normal. However, it may be helpful to have several different pediatric and adult-sized speculums available. Pelvic exams can be done in a variety of positions. Y ou may need assistants to hold a flashlight or help the patient maintain a comfortable position. Use a soothing voice, deep breathing, visualization, and praise. Consider pelvic ultrasound if bimanual exam is not possible. Consider using a short-acting benzodiazepine for sedation before a pelvic exam for women who have anxiety, spasticity, or agitation. Obtain consent from the patient or decision maker. Consider a test dose at home prior to the visit. Ask the caregiver to carefully document the patient's reaction, as well as the peak action of the medication. Consider doing the exam under conscious sedation or general anesthesia especially if the patient has a sched-uled surgical or dental procedure under anesthesia. Other exams, such as echocardiograms, labs, EKG, hearing tests, etc., can be coordinated at the same time. Used with permission from the Office of Developmental Primary Care, Department of Family & Community Medicine, University of California, San Francisco. 353 Plan
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Abuse & Neglect All adults Screen yearly with history & physical exam looking for unexplained physical and/or behavioral signs and symptoms such as unexplained bruising, falls, injuries, oral trauma, weight loss, depression, and behavior changes 16 Risk factors include caregiver stress Alcohol & Substance Abuse All adults Screen yearly with history (although best screening interval is unknown). Traditional screening tools such as the CAGE & AUDIT have not been well tested in this population 13 Breast Cancer Women aged 50-74 Mammography every 2 years17 Clinical breast exam (CBE) yearly19 Although the U. S. Preventive Services T ask Force (USPSTF) notes that there is insufficient evidence to recommend for or against the CBE, women with ID/DD may not understand the significance of breast changes or have the skills to communicate changes they notice. Also, women with sensory or neuromuscular problems may have dif ficulty performing any physical exam & some are not able to tolerate a mammogram 19 Women > 74 Individualize screening decision depending on life expectancy and comorbidities 18 Women > 18 with a family history of breast, ovarian, or other types of BRCA1 or BRCA2 gene mutations A number of risk assessment tools are available to help establish which women should be referred for genetic counseling (e. g., B-RST available at: www. breastcancergenescreen. org). Periodic (every 5-10 years) review of family history to identify increased risk. Consider referral for genetic counseling and evaluation. Comments Family history is often dif ficult to obtain in this population. Individual decision making is critical. Inform women and caregivers of potential benefits and consequences of breast cancer screening. 354 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Cervical Spine Atlanto-Axial Instability Adults with Down syndrome Perform an annual neurologic examination for signs and symptoms of spinal cord injury for patients with Down syndrome & previous negative C spine films. 1 Order cervical spine x-ray with lateral flexion and extension if symptoms develop, such as changes in behavior or activity, changes in hand preference or urinary incontinence. If this is the first C-spine film, also order an anteroposterior view. 1Consider screening cervical spine films prior to participation in athletics & before elective intubation for surgery. 2 Cervical Cancer (Women) Women ages 21-65 with average risk Perform pap smear every 3 years May use a combination of cytology and HPV testing every 5 years in women under 30 years old who prefer less frequent testing 15 Women over 65 Stop pap screening if three consecutive negative cytology tests or two consecutive negative cytology plus HPV negative tests within 10 years 15 Comments Individualized decision making depending on patient risk and sexual history. See “Tips for a Successful Pelvic Exam”: http://odpc. ucsf. edu/sites/odpc. ucsf. edu/files/pdf_docs/ Tips%20for%20a%20Successful%20Pelvic%20Exam. pdf Chlamydia Sexually active women through age 24 & older women at increased risk Nucleic acid amplification test (NAAT) (urine or vaginal or cervical swab for both)5 High risk includes multiple sex partners, h/o sexually transmitted infections, and inconsistent condom use. USPSTF notes insufficient evidence to screen men although the CDC recommends screening men who have sex with men Comments Patients may not reliably report sexual activity or symptoms. (continues)(Continued)355 Plan
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Cholesterol & Lipid Disorders Men ≥ 35 Women ≥ 45 with increased coronary heart disease (CHD) risk Order a fasting or nonfasting total cholesterol and HDL every 5 years. 17 Risk factors for CHD include previous h/o CHD or noncoronary atherosclerosis, diabetes, FHx of CVD ≤ age 55 in first-degree male relative or age 65 in first-degree female relative, tobacco use, hypertension, & obesity More frequently if patient is taking atypical antipsychotic medications or has diabetes. 17 Colorectal Cancer All adults ages 50-75 At age 50, screen with one of the following strategies: 1. Annual fecal occult blood test (FOBT) or fecal immunochemical test or 2. Flexible sigmoidoscopy every 5 years along with FOBT 3. Colonoscopy every 10 years. 17 Comments Depending on the patient's comorbidities, anesthesia risk may outweigh the benefits of colonoscopy. Patients with mobility disorders, spasticity, and/or cognitive impairment may require hospital admission the day prior to testing with colonoscopy and sigmoidoscopy for professional assistance with the bowel preparation. Dental Disease All adults Perform an annual oral exam. Refer to dentist for regular dental care including cleaning every 6 months or as recommended by the dentist Check for adequate saliva flow and amount (should be watery and abundant, not bubbly, stringy, or thick) Pay special attention to dental and gum health in persons with certain syndromes, such as Cornelia de Lange, cerebral palsy, Down, Prader-Willi, Turner, Rett, Williams, and tuberous sclerosis. 16 USPSTF recommends application of fluoride varnish on individuals with high caries risk 9,17. Comments Patients with developmental disabilities are at high risk for periodontal disease and dental caries for numerous reasons, including: difficulty maintaining hygiene, lack of access to regular dental care, syndrome-specific susceptibilities, and medication side effects (xerostomia). In some patients unable to tolerate office exams and treatment, hospital dentistry under anesthesia may be indicated. Other necessary diagnostic testing should be considered while patient is sedated. (Continued)356 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Depression All adults16 Screen annually or sooner for behaviors or emotions that may indicate depression. 11,14,16Patients with developmental disabilities may have difficulty recognizing and communicating symptoms such as depressed mood, anxiety, and sadness. Mental health symptoms are often expressed in physical or behavioral changes. It is critical that healthcare providers obtain information about the patient's usual level of functioning, skills, and behavior in order to assess the potential for mental health disorders. See Diagnostic Manual-Intellectual Disabilities for more in-depth discussion on assessment. 7 Fall Risk All adults Evaluate as part of the annual physical examination including an evaluation of the medication profile for drugs that may af fect balance and/or gait. Screen more frequently if there is a change in gait/balance or for individuals at high risk, such as those who have a history of two or more falls in the previous year. 16 For patients with no previous mobility impairments who report one or more falls, consider performing the Get-Up and Go T est: www. ncbi. nlm. nih. gov/pubmed/3487300. Patients having difficulty with this test should be referred to a physical/occupational therapist for a full fall evaluation. If the patient has had an increase in falls or a decline in function, a medical evaluation of the cause is warranted. HIV All individuals 15-65 years old Enzyme immune assay followed by confirmatory W estern blot or immunofluorescent assay or rapid HIV antibody test Screen at least once & more frequently depending on risk. Exact screening interval is unknown. 17Sexual history is often overlooked in people with ID/DD. Remember to do a periodic sexual history. 11,16,20 (continues)(Continued)357 Plan
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Hearing All adults Screen annually subjectively or objectively with of fice-based testing (Whisper Test). 16 Refer to audiology at regular intervals. Refer to audiology for hearing assessment every 5 years after age 45 (every 3 years throughout life for patients with Down syndrome). 2,6,16 Reevaluate hearing if problems are reported or changes in behavior are noted. 16 Comments Other syndromes associated with hearing impairments include Cornelia de Lange, Noonan, Usher, and Smith-Magenis. 16 Methods for testing may include the following: Method Applicable for Developmental Age (years) Oto Acoustic Emissions (OAE) > 0 Auditory Brainstem Responses (ABR) > 0 Behavioral observation audiometry > 0 Pure tone audiometry with visual reinforcement > 1 Whispered speech > 3 Pure tone (play) audiometry > 3-4 Hypertension All adults Sphygmomanometer measurement every 2 years if blood pressure ≤ 120/80 and annually if systolic 120-139 or diastolic 80-90. 8 For patients with spasticity/contractures, may need to do a wrist or thigh blood pressure measurement. Document type of measurement used. Immunizations See Centers for Disease Control and Prevention Recommended Adult Immunization Schedule: www. cdc. gov/vaccines/schedules/index. html Obesity All adults Measure height and weight annually. 14,16 Consider weight on home scale in more familiar setting. Accommodations for patients unable to stand include using a Lift Team, a wheelchair scale, Hoyer Lift, and/or hospital bed that includes a scale. Osteoporosis Women ≥ age 65 & younger women whose 10-year fracture risk is ≥ 9. 3%17 All adults with ID/ DD at high risk. 12 Bone mineral density (BMD) screening with dual-energy x-ray absorptiometry (DEXA) testing at the spine and hip earlier and at regular intervals for high-risk patients Recommended screening interval is unknown. 12,20 The typical sites for DEXA scans (lumbar spine & hip) may be very dif ficult for some individuals with mobility impairments &/or spasticity. Alternate testing methods are needed. 12- Although the age to begin screening is unclear, some authors suggest age 40 for patients residing in institutions and age 45 for patients residing in the community. 20 Check serum vitamin D 25 OH levels at regular intervals(Continued)358 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Comments High-risk factors in patients with developmental disabilities include mobility impairments, long-term use of antiepileptic drugs or antipsychotics, nutritional issues, and oral-motor problems. Patients with Down syndrome, cerebral palsy, and Prader-Willi syndrome are also at greater risk. High-risk factors in the general population include osteopenia on plain films, history of vertebral fractures, early menopause, chronic steroid use, low body weight, cigarette use, and positive family history of osteoporosis. See FRAX: WHO Fracture Risk Assessment Tool: www. shef. ac. uk/FRAX/. Note that mobility is not calculated in this assessment tool. Prostate Cancer- Insufficient evidence to recommend routine screening in men under age 75. 17 Screening not recommended for men over age 7517 Comments Family history is often difficult to obtain with this population. Patients at high risk include those with positive family history at an early age and African American men. Use shared decision-making with the patient and medical decision makers. 17 Testicular Cancer All adolescent & adult males Routine screening not recommended. Prompt assessment and evaluation of testicular problems when young men present with signs and symptoms of testicular disease. 17Risk factors for testicular cancer: previous testicular cancer, positive FHx of testicular cancer, cryptorchidism, Klinefelter syndrome Comments Clinical exam is especially important in this population who may not be able to report symptoms and may have difficulty with the self-exam technique. Thyroid Disease All adults with DD Adults with Down syndrome Monitor thyroid-stimulating hormone (TSH) regularly. Exact testing interval is unknown. 16 Check TSH more frequently in patients with Down syndrome. 2,16 Comments Symptoms of thyroid disease are often not elicited due to cognitive impairment and/or communication difficulties in patients with developmental disabilities. Consider TSH testing if unexplained change in behavior or level of functioning. Increased risk for thyroid disease seen in patients with Down syndrome and the elderly. Tuberculosis All adults with DD Screen routinely with tuberculin skin test (TST) or gamma release assay (IGRA) based on likelihood of exposure 17)IGRA if the individual is unlikely to return to have TST read or those who have had previous Bacillus Calmette-Guérin vaccination. Comments Consider tuberculin skin testing every 1 to 2 years for patients who live or work in aggregate settings (board and care homes, intermediate care facilities, day programs). (continues)(Continued)359 Plan
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Vision All adults with DD Screen annually subjectively or objectively with of fice-based tests (Snellen test). 14,16, Refer to ophthalmology for exam and glaucoma screening at least once before age 40 Refer for ophthalmologic exam and glaucoma screening every 5 years after age 45 or as recommended by ophthalmologist 16 Adults with Down syndrome Refer to ophthalmology for exam and glaucoma screening by age 30 for patients with Down syndrome. 16 Comments Screen more frequently for persons with diabetes, those on long-term psychiatric medication, and those with syndromes associated with vision deficits/ocular abnormalities, such as Cornelia de Lange, Fragile X, Down, Smith-Magenis, tuberous sclerosis, and Velocardiofacial. 16 Counseling Lifestyle Modification/ Healthy Quality of Life Discuss: Adequate calcium and vitamin D supplementation Dental hygiene Fall risk assessment and prevention Nutrition—Excellent resource is the Montana Disability & Health Program: Nutrition for Individuals with Intellectual or Developmental Disabilities, http://mtdh. ruralinstitute. umt. edu/?page_id=813 Physical activity (regular schedule with structured staff training to support & reinforce)10 Tobacco and substance abuse cessation Sexual health, including: contraception, sexually transmitted infection prevention, and healthy relationships Comments Critical to include caregivers, health advocates, and parents/family members to help reinforce teaching concepts. Advanced directives & end-of-life planning Schedule dedicated time for discussion with the individual and support team Excellent resource: Thinking Ahead Matters (End-of-Life P lanning f or P eople w ith D D, h ttp:// coalitionccc. org/tools-resources /people-with-developmental-disabilities/ Medication Review Review medications at regular intervals with patients and caregivers to ensure adherence with regimen and evaluate for side ef fects and drug interactions. Comments High rates of polypharmacy exist. See medication watch list: http://odpc. ucsf. edu/sites /odpc. ucsf. edu/files/pdf_docs/Med Fest-Medical-Watch-List. pdf(Continued)360 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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Table 38-1 Healthcare Maintenance Guidelines for Adults with Developmental Disabilities Health problem w ho to s creen test & f requency s pecial Considerations Safety Review safety practices per individual circumstance, such as stranger and street safety for patients who live independently; prevention of head trauma in patients with frequent seizures; and street safety for patients with unpredictable behavior. ©2015 Geraldine Collins-Bride, MS, ANP, FAAN. Non-commercial use with attribution is permitted. References 1. American Academy of Pediatrics Committee on Sports Medicine and Fitness. (1995). Atlantoaxial instability in Down syndr ome: Subject review. Pediatrics. 96, 151-154. 2. Bull, M. J., & the Committee on Genetics. (2011). Clinical r eport—Health supervision for children with Down syndrome. Pediatrics, 128(2), 393-406. 3. Carmeli, E., & Imam, B. (2014). Health pr omotion and disease prevention strategies in older adults with intellectual and developmental disabilities. Frontiers in Public Health, 2, 31. doi: 10. 3389/fpubh. 2014. 00031. 4. Centers for Disease Contr ol and Prevention. (2015). Immunization recommendations. Retrieved from www. cdc. gov/vaccines/schedules /index. html. 5. Centers for Disease Contr ol and Prevention. (2014). Recommendations for the Laboratory-Based Detection of Chlamydia trachomatis and Neisseria gonorrhea, MMWR March 14, 2014. Retrieved from www. cdc. gov/mmwr/preview/mmwrhtml/rr6302a1. htm. 6. Cohen, W. I. (Ed. ). (1999). Health care guidelines for individuals with Down syndrome: 1999 revision. Down Syndrome Research Foundation. 7. Fletcher, R., Loschen, E., Stavrakaki, C., & First, M. (Eds. ). (2007). Diagnostic manual—Intellectual disability: A textbook of diagnosis of mental disorders in persons with intellectual disability. Kingston, NY: NADD Press. This was published by the National Association for Dual Diagnosis and the American Psychiatric Association. 8. James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., et al. (2013). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA, 1097, 1-14. 9. Marinho, V. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, 7, CD002279. 10. Marks, B., Sisirak, J., & Chang, Y. C. (2013). Efficacy of the Health Matters program train-the-trainer model. Journal of Applied Research in Intellectual Disabilities, 26(4), 319-334. 11. Massachusetts Department of Developmental Services. (2012). Pr eventive health recommendations for adults with intellectual disability. Retrieved from www. mass. gov/eohhs/docs/dmr /reports/health-screening-brochure. pdf. 12. Petr one, L. R. (2012). Osteoporosis in adults with intellectual disabilities. Southern Medical Journal, 105(2), 87-92. 13. Pezzoni, V., & Kouimtsidis, C. (2015). Screening for alcohol misuse within people attending intellectual disability community service. Journal of Intellectual Disability Research, 59(4), 353-359. 14. Prasher, V., & Janicki, M. (Eds. ). (2002). Physical health of adults with intellectual disabilities (International Association for the Scientific Study of Intellectual Disabilities). Oxford, UK: Blackwell Publishing. 15. Sawaya, G., Kulasingam, S., Denberg, T., & Quaseem, A. (2015). Cervical cancer screening in average-risk women: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Annals of Internal Medicine, 162(12), 851-860. 16. Sullivan, W. F., Berg, J. M., Bradley, E., Cheetham, T., Denton, R., Heng, J., et al. (2011). Primary care of adults with developmental disabilities: Canadian consensus guidelines for primary health care of adults with developmental disabilities. Canadian Family Physician, 57, 541-553. 17. U. S. Pr eventive Services Task Force. (2014). Guide to clinical preventative services. U. S. Department of Health and Human Services. Retrieved from www. ahrq. gov/professionals/clinicians-providers/guidelines-recommendations/guide/index. html. 18. W alter, L. C., & Schonberg, M. A. (2014). Screening mammography in older women: A review. JAMA, 311(13), 1336-1347. doi:10. 1001/ jama. 2014. 2834 19. W ilkinson, J. E., & Cerreto, M. C. (2008). Primary care for women with intellectual disabilities. Journal of the American Board of Family Medicine, 21(3), 215-s22. 20. W ilkinson, J. E., Culpepper, L., & Cerreto, M. (2007). Screening tests for adults with intellectual disabilities. Journal of the American Board of Family Medicine, 4, 399-407. (Continued)361 Plan
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v. s elf-management resources and tools A. Healthcare provider resources 1. O ffice of Developmental Primary Care, University of California, Department of Family & Community Medicine, http://odpc. ucsf. edu 2. H ealth care for Adults with Intellectual and Developmental Disabilities: T oolkit for Primary Care Providers, http://vkc. mc. vanderbilt. edu/etoolkit/ 3. S ociety for the Study of Behavioural Phenotypes (information on specific genetic syndromes and specific health risks), www. ssbp. org. uk/syndromes . htmlc. C onsulting with a dentist regarding fluoride varnishes, rinses, and chlorhexidine rinses (National Institute of Dental and Craniofacial Research, 2009) C. Patient education 1. P rimary focus should be on developing a trusting relationship with the patient and caregivers (Figure 38-4). 2. P rovide lifestyle modification counseling to promote a healthy and happy quality of life (T able 38-1, counseling section). 3. P rovide information on community resources to support patients, caregivers, and families. 4. R eview safety practices for prevention of accidents and victimization. f IGure 38-4 Communicating with patients with d evelopmental d isabilities Person-first language was developed by disability advocates to educate the community at large. It emphasizes the individual before the disability. For example, “Tom has Down syndrome. ” Some people, especially those in the autistic, blind, and deaf communities, view their disability as an integral part of who they are. They may use identity-first language such as “autistic man” or “blind person. ” Language evolves and the disability community is diverse. It is always appropriate to inquire about and use the language your patient prefers. Avoid describing people with disabilities as overly courageous, brave, or special merely for having a disability. It is not unusual for people with disabilities to accomplish significant things and participate in and manage activities of daily living despite functional limitations. It is always appropriate to celebrate the achievement of personal goals and milestones. Also, avoid describing people with disabilities as overly pitiful and unfortunate. Most people with disabilities do not consider their lives tragic. They rate their quality of life far higher than many nondisabled people estimate. Likewise, don't assume that people are unhappy or heroic simply because they are caring for a relative or friend who has a disability. It is helpful to inquire what challenges they face and assistance they need. Most caregivers appreciate empathy and assistance if they struggle with discrimination or lack of respite and accommodation. Instead of... Use ... Afflicted with... suffers from... She has Down syndrome Confined to a wheelchair/wheelchair-bound Uses a wheelchair Caretaker Caregiver, or person who cares for, advocates for, or serves people... Handicapped parking Accessible parking Mentally retarded Person with an intellectual disability “Normal” or “healthy” Nondisabled/typical/neurotypical Used with permission from the Office of Developmental Primary Care, Department of Family & Community Medicine, University of California, San Francisco. 362 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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Anderson, L. L., Humphries, K., Mc Dermot, S., Marks, B., Sisirak, J., & Larson, S. (2013). The state of the science of health and wellness for adults with intellectual and developmental disabilities. Intellectual and Developmental Disabilities, 51(5), 385-398. Andresen, E. M., Peterson-Besse, J. J., Krahn, G. L., Walsh, E. S., Horner-Johnson, W., & Iezzoni, L. I. (2013). Pap, mammography, and clinical breast examination screening among women with disabilities: A systematic review. Women's Health Issues, 23(4), e205-e214. Autistic Self Advocacy Network, Office of Developmental Primary Care. (2014). Our lives, our health care: Self-advocates speaking out about our experiences with the medical system. Retrieved from http://odpc. ucsf. edu/sites/odpc. ucsf. edu/files/pdf_docs/Our%20Lives%20Our%20Health%20Care%20Final_0. pdf. Coppus, A. M. (2013). People with intellectual disability: What do we know about adulthood and life expectancy? Developmental Disabilities Research Reviews, 18(1), 6-16. Developmental Disabilities Assistance and Bill of Rights Act of 2000. Public Law 106-402. Retrieved from www. acl. gov/Programs/AIDD /DDA_BOR_ACT_2000/Index. aspx. Feldman, M. A., Bossett, J., Collet, C., & Burnham-Riosa P. (2014). Where are persons with intellectual disabilities in medical research? A survey of published clinical trials. Journal of Intellectual Disability Research, 58(9), 800-809. Frisch, D., & Msall, M. E. (2013). Health, functioning, and participation of adolescents and adults with cerebral palsy: A review of outcomes research. Developmental Disabilities Research Reviews, 18(1), 84-94. Horner-Johnson, W., Dobbertin, K., & Lee, J. (2013). Disparities in chronic conditions and health status by type of disability. Disability and Health Journal, 6(4), 280-286. Hwang, Y. S., & Kearney, P. (2013). A systematic review of mindfulness intervention for individuals with developmental disabilities: Long-term practice and long lasting effects. Research in Developmental Disabilities, 34(1), 314-326. Kerr, S., Lawrence, M., Darbyshire, C., Middleton, A. R., & Fitzsimmons L. (2013). T obacco and alcohol-related interventions for people with mild/moderate intellectual disabilities: A systematic review of the literature. Journal of Intellectual Disability Research, 57(5), 393-408. Kripke C. C. (2014). Primary care for adolescents with developmental disabilities. Primary Care, 41(3), 507-518. Marinho, V. C., Worthington, H. V., Walsh, T., & Clarkson, J. E. (2013). Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews, 7, CD002279. National Institute of Dental and Craniofacial Research. (2009). Practical oral care for people with intellectual disability. Bethesda, MD: National Institutes of Research. Retrieved from www. nidcr. nih. gov/oralhealth/T opics/Developmental Disabilities /Practical Oral Care People Intellectual Disability. htm. Nicolaidis, C., Kripke, C., & Raymaker, D. (2014). Primary care for adults on the autism spectrum. Medical Clinics of North America, 98(5), 1169-1191. Office of Developmental Primary Care. (n. d. ). Interdisciplinary healthcare team chart. Retrieved from http://odpc. ucsf. edu/odpc/html/for _clinicians/charts_forms_c. htm. Parker, S. E., Mai, C. T., Canfield, M. A., Rickard, R., Wang, Y., Meyer, R. E., et al. (2010). Updated national birth prevalence estimates for selected birth defects in the United States, 2004-2006. Birth Defects Research. Part A, Clinical and Molecular T eratology, 88(12), 1008-1016. Peterson, M. D., Gordon, P. M., & Hurvitz, E. A. (2013). Chronic disease risk among adults with cerebral palsy: The role of premature sarcopoenia, obesity and sedentary behavior. Obesity Reviews, 14(2), 171-182. 4. H ealth assessment forms, yearly health checks, and other information, www. cddh. monash. org/disability -health-assessment. html 5. A ASPIRE Healthcare T oolkit: Primary Care Resources for Adults on the Autism Spectrum and Their Primary Care Providers, http://autismandhealth. org/ 6. A merican Academy of Developmental Medicine and Dentistry: resources for clinicians and students on neurodevelopmental disorders and health care for adults with DDs, www. aadmd. org 7. D evelopmental Disability Nurses Association (resources for healthcare providers and families), www. ddna. org 8. C oalition for Compassionate Care of California: Addressing the needs of the intellectual and developmentally disabled community when preparing for the end of life, http://coalitionccc. org/tools-resources/people-with-developmental-disabilities/ B. Patient and caregiver resources 1. S tate of California Regional Center System, www. dds . ca. gov/RC/Home. cfm 2. S upport for Families, www. supportforfamilies. org 3. F amily Voices, www. familyvoices. org Always presume competence. This means assume that all people deserve dignity, privacy, autonomy, access, and respect. Assume all people have the potential to learn. Do not assume that someone who doesn't speak cannot understand. Assume all people communicate, all lives are meaningful and valuable and all people can learn, grow, and benefit from inclu-sion and opportunity. Speak directly to patients in a normal, adult tone of voice. Offer accommodations to help, but ask before assisting. Not all disabilities are visible and many people develop skills or find ways to accommodate their disabilities that make them less apparent to others. However, this does not mean that those individuals do not have significant challenges. referen Ces Academic Autistic Spectrum Partnership in Research and Education. (2015). AASPIRE healthcare toolkit: Primary care resources for adults on the autism spectrum and their primary care providers. Retrieved from www. autismandhealth. org/. American Academy of Pediatrics, American Academy of Family Physicians, & American College of Physicians. (2011). Supporting the health care transition from adolescence to adulthood in the medical home. Pediatrics, 128(1), 182-200. Retrieved from http://pediatrics . aappublications. org. American Association on Intellectual and Developmental Disabilities. (2010). Definition of intellectual disability. Retrieved from www. aamr . org/content_100. cfm?nav ID=21. 363 References
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United Cerebral Palsy. (2011). United Cerebral Palsy organization. Retrieved from www. ucp. org. Vanderbilt Kennedy Center for Excellence in Developmental Disabilities. (n. d. ). Healthcare for adults with intellectual and developmental disabilities: T oolkit for primary care providers. Nashville, TN: Vanderbilt University. Retrieved from http://vkc. mc. vanderbilt. edu/etoolkit/. Y eargin-Allsopp, M. (2010, March 12). Trends in the epidemiology of cerebral palsy. Keynote lecture at the Annual Update on Developmental Disabilities Conference at University of California, San Francisco, San Francisco, California. Yin Foo, R., Guppy, M., & Johnston, L. M. (2013). Intelligence assessments for children with cerebral palsy: A systematic review. Developmental Medicine and Child Neurology, 55(10), 911-918. Robertson, J., Hatton, C., Emerson, E., & Baines, S. (2014). The impact of health checks for people with intellectual disabilities: An updated systematic review of evidence. Research in Developmental Disabilities, 35(10), 2450-2462. Ross, W. T., & Olsen, M. (2014). Care of the adult patient with Down syndrome. Southern Medical Journal, 107(11), 715-721. Sobey, D., & Doe, T. (1991). Patterns of sexual abuse and assalt. Sexuality and Disability, 9(3), 243-259. Sullivan, W. F., Berg, J. M., Bradley, E., Cheetham, T., Denton, R., Heng, J., et al. (2011). Primary care of adults with developmental disabilities: Canadian consensus guidelines. Canadian Family Physician, 57, 541-553. Svien, L. R., Berg, P., & Stephenson, C. (2008). Issues in aging with cerebral palsy. T opics in Geriatric Rehabilitation, 24(1), 26-40. 364 CHAPTER 38 | Healthcare Maintenance for Adults with Developmental Disabilities
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United States have been challenging because of lack of inclusive survey or data collection forms, lack of reliability due to fear of stigma or discrimination from self-identification and overgeneralization of the term “transgender. ” Four of the nation's larg-est, most comprehensive population-based surveys collected data on sexual orientation but failed to explicitly measure gender identity outside of male or female (Gates, 2014). Worldwide data suggest 1 in 30,000 people identify as transwoman (MTF) and 1 in 100,000 people as transman (FTM) (Center of Excellence for T ransgender Health, 2014). These numbers, however, are likely underestimated. As data collection methods become more inclusive, these ratios will decrease. The terms “transgender” or “trans” are broadly used terms to describe people whose gender iden-tities, expression, and behaviors differ from their birth sex, irrespective of their physical appearance or sexual orientation (Feldman & Bockting, 2003; Kenagy, 2005). Included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) as of 1980, the term gender identity disorder has been reclassified as gender dysphoria in the current DSM-V guidelines. Labeling transgender patients with a mental disorder can be controversial and might be offensive to some individuals. For transgender patients who have concerns with the gender dysphoria diagnosis, an alternative diag-nosis of endocrine disorder NOS is appropriate. However, a clinical diagnosis is often necessary to receive insurance coverage for hormone therapy and/or surgical procedures. It is important to rec-ognize that gender is seen by many as more than a binary concept. Figure 39-1 is a graphic repre-sentation of the spectrum of gender identity and expression. I. Intr oduction and general background T ransgender people living in the United States are a margin-alized and medically underserved community. Compared to 62% of the general population, only 40% of transgender individuals who are employed have access to employer-based insurance. Unemployment rates among transgender people are twice the national average, and 27% report annual incomes of less than $20,000 (National Gay and Lesbian T askforce, 2009). Social stigmatization affects access to work, poverty contributes to housing instability, and insti-tutional barriers make accessing health care difficult, if not impossible, for many transgender patients. In fact, 30-40% of transgender persons in the United States rely on urgent care and emergency departments for their immediate healthcare needs (Feldman & Bockting, 2003). Those who do access care report difficulties finding compassionate providers with transgender health experience (Sanchez, Sanchez, & Danoff, 2009). Nearly a third of transgender patients surveyed in multiple studies report discrimination, hostility, and out-right refusal of medical care, resulting in a reluctance to seek routine and even urgent care (Herbst et al., 2008; Minter & Daley, 2003). As a result, the rates of preventable illnesses, such as HIV, are higher in the transgender community than in any other population (Centers for Disease Control and Prevention, 2015). However, it has been demonstrated that routine medical care focusing on healthcare maintenance for transgender individuals can be delivered in the primary care setting safely and compassionately, without the need for specialty or psychiatric referrals (Davidson et al., 2013). A. Transgender identity 1. D efinition and overview Data collection and epidemiologic estimates concerning the transgender community in the Melissa Wong and Kathryn Wyckoff Healt Hcare Ma Intenance for t ransgender Ind I v I duals© Eliks/Shutterstock; © donatas1205/Shutterstock 36539Chapt Er
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b. S exually transmitted infection (STI) history and HIV status, including date of last screening tests c. S urgeries, with emphasis on any feminiza-tion or masculinization procedures, such as breast augmentation (for MTFs) or mastec-tomy (for FTMs). Other surgeries include facial feminization and tracheal shaving (MTF) and sexual reassignment surgeries, such as metoidio-plasty and phalloplasty (FTM) and vaginoplasty (MTF). d. C osmetic procedures, including those done by nonlicensed laypersons, such as silicone injections e. P revious psychiatric hospitalizations and/or any suicide attempts f. M edications, with emphasis on hormonal therapy, including names of medications, dosage, route, and source (i. e., Internet, Mexico, buying from friends, and so forth) g. I mmunization status, with emphasis on hepatitis A, B, and human papillomavirus (HPV) vaccines h. H epatitis C risk factors and antibody status i. H istory of injuries, with emphasis on screening for abuse and intimate partner violence 2. F amily history, with emphasis on cardiovascular disease and cardiac risk factors 3. O ccupational history: screen for paid sex work and source of income to appropriately identify risk factors and need for support 4. P ersonal and social history including: a. L egal status of name and gender identity (important for billing and documentation) b. C itizenship/immigration status c. H istory of alcohol, tobacco, and drug use d. H istory of depression, anxiety, bipolar disorder, trauma, or suicidal ideation or attempts e. R elationships and social support network, intimate partner violence screening, social issues (being out at work/school/or to family). f. H ousing status g. F uture goals for feminization or masculinization, such as gender reassignment (or gender affirma-tion) surgery, hormone therapy, or neither. Some transgender patients may choose not to have surgery or take hormones, so it is important to establish each patient's goal. h. S uccesses and failures with gender reassignment, including issues currently concerning the patient about appearance and any issues being out to family, classmates, coworkers, etc. 2. D efinitions Male-to-female (MTF): transwoman, persons who were assigned male at birth who identify as female Female-to-male (FTM): transman, persons who were assigned female at birth who identify as male Gender-variant, bigendered, or gender-queer, gender nonconforming, agender, gender-fluid: individu-als who may be biologic males, females, or intersex individuals who choose to identify as both or neither male or female or somewhere in between the conven-tional male and female categories. Cisgender men/woman: individuals whose gender expression is congruent with sex assigned at birth. II. d atabase (may include but is not limited to) A. Subjective **Always use a transgender patient's chosen name and preferred pronoun (Appendix 39-A). 1. P ertinent past medical history, as outlined in the chapter Healthcare Maintenance of the Adult and Older Adult with focus on the following additional data: a. P revious medical illnesses, with emphasis on a history of coronary disease and/or thromboem-bolic events Figure 39-1 The spectrum of gender identity and expression Modified from Center for gender sanity. (2009). Biological Sex (anatomy, chromosomes, hormones) Male Intersex Female Gender Identity (psychological sense of self) Man Genderqueer/Bigender/Agender/Gender Fluid Woman Gender Expression (communication of gender) Masculine Androgynous Feminine Adapted from Center for Gender Sanity (2009). 366 CHAPTER 39 | Healthcare Maintenance for Transgender Individuals
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Iv. Plan A. Diagnostics (screening and secondary prevention tests) 1. S creen for diseases and conditions based on the patient's risk profile. Note that normal laboratory values are often gender specific. There are no established guidelines for determining normal laboratory values for transgender patients, but the general rule is to use the biologic gender-normal values until 2 years of hormone therapy have been completed, then use the normal values of the assigned gender (Feldman & Goldberg, 2007). 2. S imilar healthcare maintenance and screening needs as general populations. T able 39-1 outlines healthcare maintenance guidelines and special considerations for MTF and FTM trans patients (Center of Excellence for T ransgender Health, 2014). B. Treatment 1. I mmunization recommendations are not sex specific. Follow general guidelines but transgender patients who have sex with cisgender men may benefit from hepatitis A and meningococcal vaccines (Center of Excellence for T ransgender Health, 2014). 2. F or prescribing/furnishing/drug ordering guidelines for hormonal therapy, see T ables 39-2 and 39-3. Use the appropriate drug interaction database when prescribing hormone therapy to avoid adverse drug interactions, especially for patients taking HIV antiretroviral, antidepressant, and anticonvulsant medications. 3. Di scuss fertility issues and childbearing plans with any patient considering hormonal therapy as cross-sex hormones may interfere with fertility (Center of Excellence for T ransgender Health, 2014). Figure 39-2 can be used as a starting point to iden-tify appropriate feminizing therapies based on patient goals. Figure 39-3 outlines goals of masculinizing therapies. Note that the use of hormones for gender reassignment is off label and the provider should obtain informed consent before initiating therapy. 4. M TF patients: Most MTF patients can be successfully transitioned with the use of estrogen and spironolactone alone. Progesterone can also be used; B. Objective Physical examination may be deferred until strong clinician-patient relationship is established, unless review of symptoms warrants immediate examination. The patient should be prepared for the need for a physical examination in advance and given an opportunity to discuss feelings about being examined. Guidelines suggest implementing physical exams, screening and healthcare maintenance needs based on the anatomy that is present, regardless of patient's self-identification (Center of Excellence for T ransgender Health, 2014). 1. Ge nital, rectal, and breast/chest examinations may cause particular distress for patients. Discuss with the patient in advance the rationale for the examination and ascertain how the patient would like one to refer to their anatomy (i. e., genitals, instead of penis or vagina, chest instead of breasts). 2. F or patients who have had gender reassignment surgery, the clinician must become familiar with the particular surgical technique used and screen for applicable complications. 3. F or patients who have had silicone injections, the clinician should carefully examine the patient for signs of cellulitis or tissue deformity. 4. Th yroid physical examination and lab values, as cross-sex hormone use may cause endocrine imbalances. III. a ssessment A. The current risk factors and health status of the patient should be identified, the patient's motivation to change unhealthy habits should be assessed, and the patient's ability to successfully accomplish adult developmental milestones should be determined as outlined in the chapter Healthcare Maintenance of the Adult. B. Identify the patient's gender reassignment goals and barriers to the goals. Assess for benefits of hormonal gender reassignment therapy and undesirable side effects, such as weight gain and increased cardiovascular risk. C. Identify psychosocial needs of the patient. 367 Plan
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reassignment surgery require only estrogen to maintain a feminine appearance. 5. FTM p atients: Most FTM patients can be successfully transitioned with the use of testosterone alone. Baseline labs for the FTM patient considering masculinizing hormone therapy should include a complete blood count, complete metabolic profile, and fasting lipids. Check a trough level of testosterone the day before the next injection is due to determine the testosterone level at its lowest. Recheck laboratory tests after 3 months of therapy or after dose increases and then 1 year after starting. Patients should be educated that it takes approximately 2 years to transition regardless of the dosage of hormone. Increasing the dose of hormone therapy will not hasten the transitioning process. Discuss contraceptive use in FTM patients having receptive vaginal sex with male partners as testosterone does not reduce fertility and advise patients that it may take up to 6 months for menses to cease once on testosterone therapy. T estosterone dose should not necessarily be reduced after hysterectomy or sex reassignment surgery. T estosterone therapy should be continued even after maximum masculinization for osteoporosis protection. Table 39-1 Healthcare Maintenance g uidelines for the Transgender Patient Mtf ft M Prostate cancer (CA) screening per general population (prostate-specific antigen can be low, use digital rectal exam if necessary to evaluate based on review of systems) Breast CA screening by mammography in presence of other risk factors (estrogen/progestin use > 5 yrs, family history, body mass index ≥ 35) Pap smears not required if patient has neovagina but do visual inspection to look for genital warts or other lesions. Blood pressure (BP) screening prior to hormone initiation with pretestosterone goal of < 130/90 mm Hg then q 1-3 month monitoring Annual fasting lipid panel with low-density lipoprotein goal of < 135 mg/d L or < 96 mg/d L in high-risk patients Consider liver function tests (LFTs) if on hormones AND higher risk (increased alcohol use, weight gain, or at risk for hep C) s exual health screening at every visit. Based on sexual practices and may include H i V and sexually transmitted infection testing, hepatitis B & C screening and prevention. s creen for depression/suicidality at every visit Cervical CA screening per general population with the following considerations: if patient has had total hysterectomy and has prior hx of high-grade cervical dysplasia do pap of vaginal cuff until 3 normal, then q 2-3 yrs if patient has had ovaries removed but uterus/cervix is intact, follow guidelines for biologic females *note that vaginal atrophy from testosterone use can mimic dysplasia* Uterine Cancer:evaluate all spontaneous vaginal bleeding that cannot be explained by missed or changes in hormone dosing Annual chest wall/axillary exam Complete blood count, LFTs every 6 months when on hormone therapy s creen for depression/suicidality at every visit however, it may not be as effective as spironolactone in suppressing testosterone (Gooren & T angpricha, 2015). T able 39-4 outlines clinical considerations to estrogen use. Always limit estrogen to one type and use the lowest effective dose. Baseline labs for the MTF patient considering feminizing hormone therapy should include fasting lipids and glucose levels and creatinine and potassium levels in patients considering spironolactone. Recheck laboratory tests after 3 months of therapy or after dose increases and then after 1 year on a stable dose. Some providers may elect to check labs at baseline, 3 months, 6 months, and then 1 year. Monitoring prolactin levels is important, as levels can increase with the use of estradiol. Check LFT s after 1 year of therapy if patient has liver disease risks. Consider adding additional antiandrogen drugs if beard growth is not adequately suppressed or if patient becomes hypotensive on spironolactone. Finasteride may also be used to help prevent male pattern baldness. Checking testosterone levels can help with titration of antiandrogen medications. Orally dosed estrogen should be avoided in patients over 40 years old or with cardiovascular/thromboembolic risks. Patients who have had an orchiectomy or gender 368 CHAPTER 39 | Healthcare Maintenance for Transgender Individuals
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Table 39-2 Feminizing Hormone Options estrogen Preparations dosage Pr ecautions c ontraindications Interactions e stradiol Conjugated e quine e strogens (Premarin®) e stradiol Valerate (Delestrogen) e stradiol Patch (Climara®, e straderm®, Alora®, Vivelle®)s tarting: 2-3 mg daily Typical: 4 mg daily Max: 8 mg daily s tarting: 1. 25-2. 5 mg daily Typical: 5 mg daily Max: 10 mg daily s tarting: 20-40 mg i M/Q2 wk Typical: 40 mg i M/ Q2 wk Max: 40-80 mg i M/ Q2 wk s tarting 0. 1 mg/24 hr Typical: 5 mg daily Max: 10 mg daily Deep venous thrombosis, pulmonary embolism, other thromboembolism, thrombophlebitis, hypertension, impotence, prolactinoma, diabetes, nausea or vomiting, migraine or headache, gallbladder disease, abnormal liver function tests, mood disorder or depression, melasma (skin darkening), acne, lipid abnormalities, hypertriglyceridemia, increased risk of heart attack, increased risk of breast cancer, hepatitis, stroke, or other cancers Individualize treatment decision based on risk and benefit Presence of estrogen-dependent cancer Caution with: history of thromboembolism or severe thrombophlebitis, tobacco smoking, seizure disorder, CAD, DM, CHFCYP 3A4, 1A2 inhibitors/inducers antiandrogens dosage Pr ecautionsc ontraindications/ c onsiderations Interactions s pironolactone s tarting: 25-50 mg B i D Typical: 50 mg B i D Max: 200 mg B i DHyperkalemia and other electrolyte imbalances, impotence, mild diuresis Renal insufficiency Potassium > 5. 5Digoxin, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, K-sparing diuretics Finasteride s tarting: 1 mg daily Max: 5-10 mg daily Metabolized in the liver—use with caution in patients with liver abnormalitiesg ood alternative for patients who cannot tolerate spironolactone  g n RH Agonists (Nafarelin, g oserelin Leuprorelin)Refer to Hembree et al. (2009) for dosing recommendations  Recommended treatment for the adolescent trans patient as pubertal development will be thwarted, but results are fully reversible (Hembree et al., 2009). Another advantage is the lack of thromboembolic risks  Progesterone Typical: 5-10 mg daily   s uppresses gonadotropin and testosterone secretion. Less effective than spironolactone.   Modified from Tom Waddell Health Center protocols for hormonal reassignment of gender. (2013). 369 Plan
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Figure 39-2 Feminizing Therapy anti-androgens e strogen decreased facial/body hair, male pattern baldness breast development decreased libido redistribution of body fat decreased erections softening of skin mild breast growth suppression of testosterone production decreased BPH shrinkage of testes decreased libido Therapies: Spirololactone, finasteride, Gn RH agonists Therapies: transdermal estrogen, estradiol valerate injection, conjugated equine estrogens Figure 39-3 Masculinizing Therapy Androgenschanges/deepening of voice pitchincreased libidoincreased muscle mass & strengthmore hair growth on face, chest, extremitiescessation of mensesredistribution of body fatclitoral enlargement Therapies: Testosterone-intramuscular, transdermal Table 39-3 Masculinizing Hormone Options testoster one Preparations dosage Pr ecautions c ontraindications Interactions Testosterone Cypionate Testosterone Patch(Androderm®)Testosterone g el 1% (Androgel®)s tarting: 50-100 mg i M Q2 wk or 25-50 mg/wk Typical: 200 mg Q2 wk Max: 400 mg Q2 wk s tarting: 2-2. 5 mg/24 hr Typical: 5 mg/24 hr Max: 7. 5 mg /24 hr s tarting: 2. 5 mg Q am Typical: 5 mg Q am Max: 10 mg Q ami ncreased BP, erythrocytosis, abnormal hepatic enzymes, dyslipidemia, increased aggressiveness, skin irritation with patch or gels *Allergy warning— injectable testosterone may be in base of cottonseed, sesame, or peanut oils Absolute: Pregnancy, h/o testosterone responsive cancers Caution with: erythrocytosis, cardiac, hepatic, renal, or vascular disease with edema, sleep apnea d/t obesity, dyslipidemia, chronic lung disease. Warfarin Cyclosporine i nsulin Modified from Tom Waddell Health Center protocols for hormonal reassignment of gender. (2013). Table 39-4 Contraindications ( i ndividualize Risk vs Benefit) of e strogen Use History of, or current thrombophlebitis, or venous throm-boembolic disorders—pulmonary embolism, deep vein thrombosis History of, or active arterial thromboembolic disease— myocardial infarction, cerebrovascular accident e strogen-dependent tumor Hepatic dysfunction Protein C or protein s antithrombin deficiency Thrombophilic disorders Data from Lexicomp. (2015); Center for Excellence for Transgender Health. (2016). Feminizing medications for transgender clients. Retrieved from http://transhealth. ucsf. edu/pdf/protocols/Sample_3_Feminizing%20Medications. pdf; Vancouver Coastal Health Transgender Health Information Program. (2016). Feminizing hormones. Retrieved from http://transhealth. vch. ca/medical-options/hormones/feminizing-hormones. 370 CHAPTER 39 | Healthcare Maintenance for Transgender Individuals
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6. P articular emphasis should be placed on smoking cessation strategies for patients receiving estrogen therapy because of the increased risk of thromboembolus. Aspirin 81 mg may be added for cardiovascular protection. 7. C onsider referring HIV-positive patients for care at a specialty clinic, unless the provider is trained in HIV/AIDS. 8. C onsider a psychiatric or mental health referral for patients who have mental illnesses, such as depression. Routine referral for psychiatric care is not otherwise warranted and may alienate patients, but note that one or more psychosocial assessments is often a prerequisite for patients considering gender transition surgery. C. Surgical Options 1. I f patient is interested in surgical intervention, assess risks and benefits. Provide patient with surgical options and education. (See T able 39-5 for common surgical options. ) Table 39-5 s urgical Options for the Transgender Patient Male to female (M tf ) female to Male ( ft M) Breast Augmentation/Implants: saline or silicone implants to create larger, female-appearing breasts. Mastectomy: Also called “top surgery,” this is the removal of female breast tissue with alteration and reconstruction of surrounding area to create a male-appearing contoured chest Facial Feminization: a range of aesthetic plastic surgery procedures that can augment proportions of a male face for more feminine facial features. May include brow lift, rhinoplasty, cheek implants, and lip augmentation. Hysterectomy: removal of uterus and/or total removal of uterus and cervix Thyroid chondroplasty (chondrolaryngoplasty): sometimes referred to as “tracheal shaving,” this is the surgical reduction of the thyroid cartilage to reduce appearance of an “Adam's apple,” associated with male characteristics. Salpingo-Oophorectomy: removal of fallopian tubes and ovaries. This procedure results in irreversible infertility unless embryo banking has been done prior to surgery. Orchiectomy: s urgical removal of testicles which results in reduced levels of testosterone in body. Results in irreversible infertility unless sperm banking done prior to surgery. Vaginectomy: Removal of the vagina Penectomy: s urgical removal of penis with relocation of urethral opening to allow for urination in sitting position. Colpocleisis: s urgical closure of the vagina, often performed when patients choose metoidioplasty or phalloplasty procedures. Vaginoplasty: s urgical creation of vaginal canal. g oal of surgery is to create a neovagina that has sensation and is wide enough and long enough for sexual penetration. Metoidioplasty: s urgical creation of a phallus using existing genital tissue. e xpected phallus size is smaller than average male penis but testosterone use for 2+ years prior to surgery may help add length to new phallus. s uccessful metoidioplasty results in some level of retained sensation and erectile capability. Labiaplasty: s urgical creation of labia minora and majora using skin from existing penis and scrotum. Scrotoplasty: s urgical creation of scrotum using existing tissue from genital area and testicular implants. Clitoroplasty: s urgical creation of clitoris Phalloplasty: Highly complex surgical construction of a penis using skin from abdomen, forearm, or inner thigh. Differs from metoidioplasty in that new phallus length is closer to average male penis and erections are possible only through permanently implanted rod or use of implanted pump. *Note that patients may choose different levels of surgery and that many of the surgery options may be completed at the same time for optimal results. Refer to the San Francisco Department of Public Health Trans Health Services reference for more detail. Modified from San Francisco Department of Public Health Transgender Health Services Resources. 371 Plan
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