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.
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