HROB Stickers--Problems/Plans

ABNORMAL QUAD (TETRA) SCREEN FOR __________

Obtain level II (dafus) ultrasound, refer for perinatology and genetic counseling.

ADRENO-GENITAL SYNDROME, previous child

Immediately, start Dexamethasone 20mcg/Kg pre-pregnancy weight divided TID
At 10 weeks, draw maternal blood for fetal sex, Contact lab for Harmony Prenatal DNA testing
If male, stop Dexamethasone and refer to Perinatologist for DAFUS and consult
If female, continue Dexamethasone and refer to Perinatologist for DAFUS, amniocentesis and consult

ADVANCE MATERNAL AGE

Offer 2nd trimester Tetra screen
Recommend Level II (DAFUS) Ultrasound and Genetic Counseling

ALLERGY TO PENICILLIN

If GBS positive, send the GBS culture for sensitivity to clindamycin and erythromycin.

ANEMIA, SEVERE

Draw anemia in pregnancy panel
Treat vitamin deficiency
Refer to HROB if hemoglobinopathy
Follow Anemia in pregnancy guideline

ASYMPTOMATIC BACTURIA

Urine culture 1st prenatal
TOC date_____
Urinalysis with reflex by clean catch every visit
Treat any level of bacteria

CARDIAC ANANOMALIES, current pregnancy

If suspected anomaly found during screening ultrasound in Bethel, refer to ANMC for DAFUS and fetal echocardiogram.
Return to HROB meeting after the ANMC visit to discuss and plan for subsequent care.

CHRONIC HEPATITIS B VIRUS (HBV) INFECTION

HBSAg positive
Draw Liver Enzymes, HBV DNA
If HBV DNA positive, refer to Hepatology for possible anti-viral therapy
ALL neonates born to mother with a positive HBSAg WILL receive HBIG and HBV vaccine at birth.

CHRONIC HYPERTENSION

Consult HROB on call at 1st prenatal visit
Baseline testing: 24 hour urine protein, comprehensive panel, EKG at first visit
Stop Medication at first visit and recheck BP in 1 week
Aspirin 81mg daily weeks 12 to 36
Ultrasound for growth weeks 24, 28, 32, 36
Start antenatal testing at 34 weeks, NST, AFI weekly
Repeat labs for suspected Gestational Hypertension
Consult obstetrician at 38 weeks for delivery plan

CONGENITAL ADRENAL HYPERPLASIA, previous child

Immediately, start Dexamethasone 20mcg/Kg pre-pregnancy weight divided TID
At 10 weeks, draw maternal blood for fetal sex, Contact lab for Harmony Prenatal DNA testing
If male, stop Dexamethasone and refer to Perinatologist for DAFUS and consult
If female, continue Dexamethasone and refer to Perinatologist for DAFUS, amniocentesis and consult

DIABETES, PRE-PREGNANCY

Consult Obstetrician for medication
Recommend split dose NPH/Regular insulin
Baseline testing: 24 hour urine protein, comprehensive panel, EKG, TSH
Optometry referral
Consider 1st Trimester screening for aneuploidy
Refer for Level II (DAFUS), Fetal Echo and Perinatologist
Transfer of Care at 30 weeks to Anchorage

DILATED FETAL RENAL PELVIS

Ultrasound at 32 weeks or as directed by consultant
If > 8mm, notify pediatrician after delivery
If < 8mm, take no action, this is normal.

ELEVATED MSAFP

OBTAIN LEVEL II (DAFUS) ULTRASOUND, REFER FOR PERINATOLOGY AND GENETIC COUNSELING
Watch for: IUGR, PREECLAMPSIA, PRETERM LABOR, VAGINAL BLEEDING
ULTRASOUND AT 32 WEEKS or as directed consultant

FETAL GROWTH RESTRICTION, Suspected

Obtain an US for fetal Growth
If US shows EFW<10% send to Anchorage for US and Perinatology consultation.
Follow Plan per Perinatology consultation

GENITAL HERPES

Inspection of vulva and vagina at 36 weeks and in labor
Encourage acyclovir 400mg three times daily for prophylaxis at 36 weeks or 4 weeks before delivery

GESTATIONAL DIABETES

Goal: Fasting <95, 2 hour PP <120
Close monitoring until controlled (weekly visits or contact)
If poor control, review at HROB and stay in Bethel after 32 weeks
If on medication, stay in Bethel at 32 weeks.
NST 2x and AFI weekly if medication or poor control after 32 weeks.

GESTATIONAL PRURITIS – ITCHING WITHOUT LAB ABNORMALITIES

Do not start Ursodiol
Repeat Bile Acids and LFT every 2 weeks.
BPP weekly starting at 32 weeks.

GRAND MULTIPARA (5 or more deliveries)

Type & Screen on admission in labor
Active management of 3rd Stage recommended
Discuss Birth Control Plans at 36 weeks
Sign Sterilization consent at 20 week visit

GROUP B STREP BACTURIA in current pregnancy

Any level of GBS in the urine at any time of the pregnancy initiates this plan
Do not do screen at 36 weeks.
Begin prophylaxis in labor per protocol.

GROUP B STEP, PREVIOUS PREGNANCY WITH CULTURE AT TERM, BUT BABY WITH NO INFECTION

No treatment is indicated
Screen at 35-37 weeks per routine protocol.

GROUP B STEP, PREVIOUS BABY WITH INVASIVE DISEASE

Screen for bacteria per the routine.
Do Not screen at 35-37 weeks.
Treat in Labor per protocol.

HISTORY OF DOMESTIC VIOLENCE

Discuss at every visit.
Monitor for signs or symptoms of abuse
Offer counseling or referral for services.

HISTORY OF DEPRESSION/POST PARTUM DEPRESSION

Screen every visit for depression
Contact Impact for score >9
Consider SSRI post partum

HISTORY OF INTRAHEPATIC CHOLESTATIS

Draw baseline bile acids and liver enzymes at first visit
Monitor for symptoms at every visit
If severe clinical symptoms, redraw labs above and begin ursodiol 15 mg/kg divided BID.
See guideline

HISTORY OF MOLAR PREGNANCY

Make sure first trimester US has history of Molar pregnancy as a diagnosis
Review the US with HROB physician
Refer patient to HROB meeting
Send Placenta for pathology after delivery.

HISTORY OF PREECLAMPSIA

Consider baseline labs: 24 hour urine protein, CBC, PIH panel
Monitor for signs or symptoms of preeclampsia and repeat labs as needed

HIGH RISK FOR PRETERM BIRTH

Reason __________
Recommend Progesterone 200mg vaginally daily 16 – 36 weeks
HROB meeting discussion or consult obstetrician
BIB date __________
CCUA with reflex every visit
Cervical length at 20-24 weeks
Treat BV if symptomatic

HISTORY OF POST PARTUM HEMORRHAGE

Type & Screen on admission in labor
Second IV in labor
Active management of 3rd Stage recommended

HISTORY OF SEIZURE DISORDER

Begin Folic Acid 4gm daily ASAP
Draw Drug level for current medication
Consult HROB for possible medication change
Level II (DAFUS) US at 18-22 weeks in Anchorage
Monitor symptoms and drug levels as needed
Monitor drug levels Postpartum as physiology changes

HISTORY OF SKELETAL DYSPLASIA OR DWARFISM

If this occurs in any pregnancy, refer for genetic counseling.
If counseling states there is a recurrence risk, refer to ANMC Perinatology at 1st Prenatal Visit.
Refer all patients for DAFUS and consultation at ANMC
Follow plan from ANMC Perinatology note

HISTORY OF SUBSTANCE ABUSE

Discuss at EVERY visit
Monitor for signs or symptoms of abuse
Social services referral
Urine drug screening recommended frequently

HISTORY OF PREECLAMPSIA with SEVERE FEATURES/ECLAMPSIA

Aspirin 81mg daily from 12 to 36 weeks.
Baseline labs: Protein/Creatinine ratio, CBC, PIH panel
Monitor for signs or symptoms of preeclampsia and repeat labs as needed

HISTORY OF STILLBIRTH

At first prenatal, attempt to locate the post stillbirth workup in the chart and document the results in your note for HROB conference.
Add Total and fractionated Bile Acids to the 1st OB visit labs.
Ultrasound for growth at 24, 28, 32 and 36 weeks.
Visits every 2 weeks in Bethel after 28 weeks.
Fetal Kick counts after 28 weeks
Further planning after HROB meeting based on other diagnoses and risk factors. See ACOG Practice Bulletin 102 Management of Stillbirth

HYPERTHYROID prior to pregnancy

Draw TSH, Free T4 and Total T4 at first visit and at least each Trimester.
If s/p ablation on replacement, consider increasing dose by 25%.
If on Methimazole, change to PTU for first trimester.
If on PTU, continue at present dose.
Switch to Methimazole as directed by ANMC consultants.
Monitor for signs and symptoms of hyperthyroid disease at every visit.

HYPERTHYROID new diagnosis

Draw TSH, Free T4 and Total T4 at first visit and at least each Trimester.
Observe carefully for signs and symptoms of Thyroid storm.
Avoid anti-thyroid medication in 1st trimester if possible.
If tachycardic, start Atenolol 25mg daily
Begin PTU at 50mg po TID, draw labs weekly until stable.
Monitor for signs and symptoms of hyperthyroid disease at every visit.

HYPOTHYROID prior to pregnancy

Consider increase of 25% in medication
Order TSH, Free T4 and Total T4 every trimester

HYPOTHYROID new diagnosis

Begin levothyroxine ASAP
Check TSH; free T4 monthly until dosage stable
Check TSH, free T4 every trimester thereafter
Re-evaluate postpartum

INTRAHEPATIC CHOLESTASIS – Severe itching and abnormal Labs

Start ursodiol 15 mg/kg divided BID
Start weekly BPP at 32 weeks
Redraw Bile Acids and LFTs weekly after 32 weeks
May return home with weekly visits
Consult HROB meeting or obstetrician
Severe IHCP if Total BA >40, must be induced by 37 weeks.
Send to Anchorage by 37 weeks

IUGR see Fetal Growth Restriction

Obesity

If BMI >40, refer to HROB for consultation.
If BMI >40 and patient 36 weeks gestation or later, Consult HROB on call and on call anesthesia
Obtain US for growth at 28, 32 and 36 weeks.

POSITIVE ANTIBODY SCREEN

Confirm antibody identification
Contact Obstetrician or discuss at HROB ASAP
Order Father of Baby Antigen test for the identified antigen
Monthly antibody titers of the identified antibody
If antibody titer increases by 2 dilutions, refer to Perinatologist for Plan

POSITIVE HIV SCREEN

Confirm HIV status with HIV rapid test and Western Blot
Order labs: CD4 Count, HIV genotype, HIV 1 RNA (Viral Load), CMP, CBC, LFT, Toxoplasm IgG, CMV IgG, RPR, HCV AB, GC/CT, PPD or Quantiferon.
Refer to Early Intervention and Perinatology at ANMC.

PREECLAMPSIA in current pregnancy

Prenatal visits weekly
Weekly Labs CBC, AST, ALT, Uric Acid, Creatinine, BUN, protein/Creatinine ratio and 24 hour urine as needed
NST 2x/week, AFI weekly
US OB follow-up for growth every 3 weeks
If Growth restriction suspected, refer to ANMC ASAP
Consult with HROB at EVERY VISIT
Refer to North Wing Physician for delivery at 38 weeks for delivery

PREVIOUS CESAREAN

If considering repeat cesarean in Bethel, appointment with obstetrician ASAP
Refer to HROB meeting for discussion
Elects TOL at ANMC, _____
Elects TOL at Bethel, _____
Elects Cesarean ANMC, Bethel, _____
TOL consent signed

RH NEGATIVE

Repeat Type and Screen with Rhogam work up at 28 weeks.
If RH negative, Give Rhogam at 28 weeks.
At delivery, follow OB policy for Rh negative patients.

RUBELLA NON-IMMUNE

Repeat Rubella vaccine postpartum if the patient has fewer than 2 immunizations ever

TWIN GESTATION 16-18 Weeks

TV sono for cervical length
Check largest vertical pocket of fluid for each twin
Discuss risks of twin pregnancy (PTD, PEC, PPH/anemia, mal-presentation, C/S)

22 Weeks

Prenatal check in Bethel – all checks after this must be in Bethel
Complete/Anatomy US

24 Weeks

Ultrasound for discordance-consider TV sono for Cervical length
1 hr GST, CBC, start FeSO4 BID

26 Weeks

Prenatal visit

28 Weeks

Ultrasound for discordance and TV sono for cervical length

30 Weeks

BE IN BETHEL due to high risk pregnancy **

31 Weeks

Prenatal check

32 Weeks

Transfer to ANMC until delivery**

UTI IN PREGNANCY

Urine Culture each trimester
qhs prophylaxis after 2nd UTI or 1st pyelonephritis
Results: 1st _____ 2nd _____ 3rd _____'

VBAC in Bethel, Planned

Discuss Case at HROB meeting
At BIB, provider will contact the HROB on call
HROB on call will contact: Blood Bank lead, OB charge nurse, OR charge nurse.
On admission in labor: CBC, Type and Screen. Admitting physician will notify: OR team on call, HRO B on call.
_ VBAC Consent signed?

category:Women's Health