KEY POINTS FOR PRACTICE
• Noninvasive prenatal testing with cell-free DNA for aneuploidy screening is recommended because of its high accuracy.
• Early evaluation of maternal pelvic floor muscle function should be considered because antepartum pelvic floor physical therapy can reduce urinary incontinence in late pregnancy and up to 6 months postpartum.
• To prevent preeclampsia in high-risk patients, 100 to 150 mg of aspirin is recommended because it has stronger evidence of benefit than an 81-mg dose.
• Interpersonal psychotherapy or cognitive behavior therapy are options to help reduce depressive symptoms during pregnancy and the postpartum period.
From the AFP Editors
Despite decreasing birth rates, approximately 3.6 million births occurred in the United States in 2021. Although perinatal infant mortality rates have decreased, maternal deaths have increased. These guidelines from the U.S. Department of Veterans Affairs and U.S. Department of Defense (VA/DoD) update their previous recommendations and reflect a more rigorous development approach. Recommended options represent strong evidence and a distinct likelihood of benefit, whereas suggested options represent weak evidence or a weak likelihood of benefit.
PRENATAL CARE
Telemedicine
Using telemedicine results in fewer overall patient visits and higher patient satisfaction and is suggested as a complement to routine prenatal and postpartum care. Lactation support using telemedicine is suggested to increase lactation up to 6 months postpartum.
Work Recommendations
Based on older studies, being active, including working, throughout pregnancy appears to be beneficial, and the guidelines continue to suggest it. The benefits of continued physical activity outweigh the risk of adverse pregnancy outcomes. After 28 weeks' gestation, work should be limited to 40 hours per week because physically demanding work and prolonged standing can increase the risk of preterm birth and hypertensive disorders of pregnancy.
Aneuploidy Screening
Noninvasive prenatal screening for aneuploidies is recommended using cell-free DNA testing of maternal blood, which can screen for trisomies 13, 18, and 21 and sex chromosome aneuploidies with high accuracy. Based on a large systematic review, sensitivity and specificity are greater than 98% for each trisomy, much higher than previous methods. Although previous screening often included alpha fetoprotein measurement, the guideline recommends offering it separately between 15 and 20 weeks' gestation.
Pelvic Floor Health
In a new recommendation, evaluation of pelvic floor muscle function at the beginning of pregnancy is suggested because emerging evidence indicates that initiation of pelvic floor physical therapy during pregnancy prevents urinary incontinence in late pregnancy and up to 6 months postpartum. Pelvic health rehabilitation improves quality of life for patients with post-partum incontinence.
PREVENTING PREGNANCY COMPLICATIONS
Nutritional Deficiencies from Previous Bariatric Surgery
Although the guideline suggests evaluating patients who have undergone bariatric surgery for nutritional deficiencies, there is insufficient evidence for or against routine supplementation of vitamins A, D, E, or K.
Preeclampsia
Strong evidence supports initiation of low-dose aspirin at or before 16 weeks' gestation in patients at risk of developing preeclampsia. The guideline recommends aspirin for these patients, suggesting doses of 100 to 150 mg daily, because subgroup analysis of 23 trials involving 26,952 patients suggests these doses reduce risk of preeclampsia, whereas 81 mg daily does not.
The Dietary Approaches to Stop Hypertension diet should be considered for patients at risk of preeclampsia because six trials demonstrated a reduction in preeclampsia incidence.
Based on limited evidence, self-monitoring of blood pressure during pregnancy and the postpartum period does not appear to reduce preeclampsia.
Preterm Delivery
The guidelines suggest vaginal progesterone and cerclage to prevent preterm delivery in at-risk patients. In patients with a cervix length of 25 mm or less or who have a history of spontaneous preterm birth, vaginal progesterone may reduce risk of spontaneous preterm birth. Cerclage appears to be effective in patients with a short cervix, whether they have a history of preterm birth or not.
The benefit of aspirin to reduce preterm birth is unknown, although in one study aspirin was not effective.
Fetal fibronectin measurement has a limited role in patients in discriminating false from true preterm labor. A fetal fibronectin level is obtained in symptomatic patients between 24 and 34 6/7 weeks' gestation only if a positive result would help inform a decision for transfer to a higher level of care.
Substance Misuse
The guideline recommends screening for use of tobacco, nicotine, alcohol, cannabis, illicit drug products, and inappropriate use of prescription medications. Of the nearly 10% of patients who consume alcohol during pregnancy, one-third report other substance use.
Depression
The guideline recommends periodic depression screening using a standard tool, which is more effective than clinical assessment. The Patient Health Questionnaire and Edinburgh Postnatal Depression Scale are validated in pregnancy and have 83% concordance. The guideline strongly recommends interpersonal psychotherapy or cognitive behavior therapy for pregnant patients at risk of depression because of a reduction in intrapartum and postpartum depressive symptoms. The guidelines also suggest offering adjunctive peer support and recommending exercise, mindfulness, yoga, or any combination to improve depressive symptoms.
Posttraumatic Stress Disorder
Active posttraumatic stress disorder (PTSD) symptoms are associated with adverse pregnancy outcomes and postpartum depression and anxiety. For those with PTSD, the guideline suggests screening for active symptoms and offering treatment early in pregnancy.
INDUCTION OF LABOR
Because perinatal and maternal complications increase as a pregnancy extends beyond term, induction of labor should be considered. The guideline strongly recommends induction of labor at 41 weeks' gestation, which decreases perinatal mortality and reduces cesarean deliveries without negatively impacting other outcomes. Induction at 39 weeks' gestation can be considered because a large trial demonstrated a reduction in cesarean deliveries without any increases in negative maternal or perinatal outcomes.
G-TRUST SCORECARD
| Score | Criteria |
|---|---|
| Yes | Focus on patient-oriented outcomes |
| Yes | Clear and actionable recommendations |
| Yes | Relevant patient populations and conditions |
| Yes | Based on systematic review |
| Yes | Evidence graded by quality |
| Yes | Separate evidence review or analysis in guideline team |
| Yes | Chair and majority free of conflicts of interest |
| Yes | Development group includes most relevant specialties, patients, and payers |
| Overall – useful |
Note: See related editorial, Where Clinical Practice Guidelines Go Wrong, at https://www.aafp.org/afp/gtrust.html.
G-TRUST = guideline trustworthiness, relevance, and utility scoring tool.
Copyright © 2017 Allen F. Shaughnessy, PharmD, MMedEd, and Lisa Cosgrove, PhD. Used with permission.
Editor’s Note: Dr. Bybel was a member of the development committee for this guideline.
This guideline is valuable because of its breadth, especially for the 16% of family physicians who deliver babies and the 18% who provide outpatient obstetric care, according to the 2017 AAFP member survey. Whereas other guidelines, including practice bulletins from the American College of Obstetrics and Gynecology, tackle elements of pregnancy care, this is the only guideline I have seen that summarizes the most important recommendations for pregnancy care as a whole.
—Michael J. Arnold, MD, Assistant Medical Editor
The views expressed are those of the authors and do not necessarily reflect the official policy or position of the U.S. Army, U.S. Department of Defense, or U.S. government.
Guideline source: U.S. Department of Veterans Affairs and U.S. Department of Defense
