HROB Stickers--Problems/Plans
Last updated 11/19/2024
2 VESSEL UMBILICAL CORD
See Guideline for Management of isolated soft ultrasound markers for aneuploidy in the second trimester
ADRENO-GENITAL SYNDROME, previous child and same FOB
At 10 weeks, draw MaternaT 21 to determine fetal sex.
When results of MaternaT 21 are complete, send Perinatology referral for a plan of management.
DO NOT start high dose dexamethasone.
ADVANCE MATERNAL AGE, age 35-39
Recommend MaternaT 21 at 10-12 weeks before the patient’s appointment in Anchorage at 20 weeks
Offer 2nd trimester MSAFP screen
Recommend referral to Perinatology for DAFUS and Genetic Counseling.
ADVANCE MATERNAL AGE, age 40 plus
Recommend MaternaT 21 at 10-12 weeks before the patient’s appointment in Anchorage at 20 weeks
Offer 2nd trimester MSAFP screen
Recommend referral to Perinatology for DAFUS and Genetic Counseling.
NST-AFI weekly starting at 36 weeks
Recommend delivery by EDD
ALLERGY TO PENICILLIN
If GBS positive, GBS culture will automatically reflex in lab for sensitivity to clindamycin and erythromycin.
AMNIOTIC BAND/
Refer to Perinatology
ANEMIA, Hg <11
Follow Anemia in pregnancy guideline
ASYMPTOMATIC BACTURIA
Test of cure (TOC) at next appointment
Urine culture every visit
Treat any level of bacteriuria
cardiac anomalies in fetus, current pregnancy
If suspected anomaly found during screening ultrasound in Bethel, contact HROB and Perinatologist for a plan of care.
Document plan of care in patient note and problem list
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 detected with a specific titer over 10IU, refer to Hepatology for possible anti-viral therapy.
If HBV DNA not detected or detected <10IU, do not sent referral.
ALL neonates born to mother with a positive HBsAg WILL receive HBIG and HBV vaccine at birth with parental consent.
CHRONIC HYPERTENSION
Consult HROB or OB/GYN on call at 1st prenatal visit or at diagnosis
Baseline testing: Urine protein/creatinine ratio, comprehensive metabolic panel.
Consider EKG/Echocardiogram if longstanding hypertension or multiple medications. HROB meeting will decide if these are necessary.
Consider Stopping medication and rechecking blood pressure in 1 week.
Change Medication to labetalol or metoprolol if possible, if on amlodipine, ok to continue
Aspirin 162mg daily from 12 weeks until delivery
Ultrasound for growth weeks 24, 28, 32, 36
Start antenatal testing at 34 weeks, BPP weekly
Repeat labs for suspected superimposed Preeclampsia, if found, contact HROB or OB/GYN for plan of care. Discuss at every prenatal visit with HROB or OB/GYN.
Consult obstetrician at 37 weeks for delivery plan
CONGENITAL ADRENAL HYPERPLASIA, previous child
At 10 weeks, draw MaternaT 21 to determine fetal sex.
When results of MaternaT 21 are complete, send MFM referral for a plan of management.
DO NOT start high dose dexamethasone.
DIABETES, PRE-PREGNANCY
Aspirin 162mg daily from 12 weeks until delivery
Consult Obstetrician for medication
Recommend insulin starting with NPH.
Baseline testing: Protein/creatinine ratio, comprehensive metabolic panel, TSH.
Consider EKG/Echocardiogram if longstanding disease, severe/brittle disease or co-morbid conditions. HROB meeting will decide if these are necessary.
Optometry referral
Recommend 1st Trimester screening for aneuploidy, using MaternaT 21
Refer to Perinatology for DAFUS, Fetal Echo and consultation
Transfer of Care to Anchorage depends on patient adherence to plan of care and glucose control. Could be any time from 30 weeks to 35 weeks.
DILATED FETAL RENAL PELVIS (UTD)
See Guideline for Management of isolated soft ultrasound markers for aneuploidy in the second trimester
ELEVATED MSAFP
Verify information sent to LabCorp for calculating results
Obtain ultrasound for dating if not already done.
Resubmit for recalculation if necessary
If AFP MOM <3.0, repeat AFP. If MOM still >2.5, or initial result is >3.0, refer to Perinatology for DAFUS and genetic counseling.
In third trimester, watch for: IUGR, preeclampsia, preterm labor, vaginal bleeding. Consult HROB or OB/GYN if these occur.
Ultrasound at 32 weeks or as directed by the Perinatologist
FETAL GROWTH RESTRICTION, Suspected
Obtain an ultrasound for fetal Growth
If US shows EFW<10%,
Obtain cord Doppler
Send images to Perinatologist
Follow recommended plan of care from Perinatologist
If ultrasound shows EFW>10%, contact HROB or OB/GYN for plan of management.
GENITAL HERPES
Inspection of vulva and vagina at 36 weeks and in labor
Encourage valacyclovir 500mg BID for prophylaxis at Be in Bethel visit or 4 weeks before planned delivery
Gestational Diabetes
Goal: Fasting <95, 2 hour postprandial <120 or 1 hour postprandial <140
Close monitoring until controlled (weekly visits or contact).
Weekly discussion at HROB rounds
Growth US at 36 weeks
If poor control (>25% of values above goal)
consider medical therapy (insulin(preferred) or oral medication)
stay in Bethel after 32 weeks
If the patient is not providing data through finger stick glucose monitoring, offer Continuous glucose monitor.
If the patient is not providing any data from any method of testing, transfer to Anchorage at 35 weeks or sooner.
GESTATIONAL DIABETES, POOR CONTROL
Consult HROB or OB/GYN at every visit for patients in poor control (>25% of values above goal) to update the plan of care.
Transfer to Anchorage at 32 weeks
GESTATIONAL DIABETES, ON MEDICATION
Insulin is preferred medication. Only use oral medication if the patient refuses insulin.
Goal: Fasting <95, 2 hour postprandial <120 or 1 hour postprandial <140
Close monitoring (weekly visits or contact).
Weekly discussion at HROB rounds
Adjust medication weekly until goal achieved.
Weekly BPP after 32 weeks. (stay in Bethel)
Transfer to Anchorage at 32-35 weeks depending on patient participation with the plan of care and glucose control.
GESTATIONAL HYPERTENSION/PREECLAMPSIA in current pregnancy
Prenatal visits twice a week
Weekly Labs CBC, CMP, protein/Creatinine ratio. 24-hour urine as recommended by HROB or OB/GYN physician.
NST 2x/week, AFI weekly
US OB follow-up for growth every 3 weeks
If Growth restriction suspected, contact HROB or OB/GYN for a plan.
Consult with HROB or OB/GYN at EVERY VISIT
Refer to North Wing Physician for delivery at 38 weeks
Gestational pruritus
Do not start Ursodiol
Repeat Bile Acids and LFT every 1-2 weeks.
GESTATIONAL PRURITUS WITH LAB ABNORMALITIES OR SEVERE PRURITUS
Lab abnormalities: Cholic acid > 3.0, elevated AST, ALT, bilirubin or alkaline phosphatase > 300.
Severe itching is excoriations, scratching during appointment, itching that alters sleep
Start ursodiol 600mg po BID. Treat as Cholestasis.
NST weekly after 32 weeks.
Induce at 39 weeks.
GRAND MULTIPARA (5 or more deliveries)
Active management of 3rd Stage recommended
Discuss Birth Control Plans at 36 weeks
Sign Sterilization consent at 20 week visit, if considering sterilization
GROUP B STREP BACTERIURIA in current pregnancy
Any level of GBS in the urine at any time of the pregnancy initiates this plan
Do not do screen with vaginal/rectal swab at 36 weeks.
Begin prophylaxis in labor per guideline.
GROUP B STEP, PREVIOUS BABY WITH INVASIVE DISEASE
Screen for bacteriuria per the routine.
Do Not screen with vaginal/rectal swab at 36 weeks.
Begin prophylaxis in labor per guideline.
GROUP B STEP, PREVIOUS PREGNANCY WITH POSITIVE CULTURE AT TERM, BUT NO NEONATAL INFECTION
No treatment is indicated
Screen at 36 weeks per routine protocol
HBsAg POSITIVE, NEW FINDING
Draw LFTs, HB core IgM, HBeAg, HBeAb, HBsAb, HB DNA PCR
Refer to ANMC hepatology
HIGH RISK FOR PRETERM BIRTH
Reason:
HROB meeting discussion or consult OB/GYN
If recommended, start progesterone 200mg per vagina qhs 16 – 36 weeks
Urine culture every visit
Serial cervical length every 2 weeks from 16- 24 weeks
If cervical length less than 30mm, see sticker for short cervix of the “Guideline Preterm Labor: Screening and Prevention”
Treat BV if symptomatic (screening for BV is not indicated)
HISTORY OF DEPRESSION/POST PARTUM DEPRESSION
Screen every visit for depression
Contact ACT or Behavioral Health for score >9
Consider SSRI postpartum
HISTORY OF DOMESTIC VIOLENCE
Discuss at every visit.
Monitor for signs or symptoms of abuse
Offer counseling or referral for services.
HISTORY OF INTRAHEPATIC CHOLESTATIS
Draw baseline total bile acids and liver enzymes at first visit
Monitor for symptoms at every visit
If severe clinical symptoms, redraw labs above and begin Ursodiol 600 mg BID.
See guideline
HISTORY OF IUGR OR SMALL FOR GESTATIONAL AGE (SGA) <20% FETUS
Growth scans at 24, 28, 32 and 36 weeks
HISTORY OF A LARGE FOR GESTATIONAL AGE (LGA) >90% FETUS OR >4000GM
Screen for Gestational Diabetes per protocol
Ultrasound at 36 weeks for growth
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 POSTPARTUM HEMORRHAGE
Second IV in labor
Standard: T&S in labor and assessment for risk of postpartum hemorrhage
Active Management of 3rd stage of labor
Consider prophylactic Tranexamic Acid
If PPH risk score is 3 prior to induction of labor, transfer care to Anchorage prior to induction. Contact OB unit to help with calculating the score if needed.
HISTORY OF GESTATIONAL HYPERTENSION/PREECLAMPSIA with or without SEVERE FEATURES/ECLAMPSIA
Aspirin 162mg daily from 12 until delivery.
Baseline labs: Protein/Creatinine ratio, CBC, CMP.
Monitor for signs or symptoms of preeclampsia and repeat labs as needed
HISTORY OF SEIZURE DISORDER
Begin Folic Acid 4mg daily ASAP
Draw Drug level for current medication
Consult HROB or OB/GYN for possible medication change
DAFUS US at 18-22 weeks in Anchorage
Monitor symptoms and drug levels as needed
Monitor drug levels Postpartum as physiology changes
Consider adding vitamin K 10mg daily from 36 weeks to delivery
Do not give Tdap vaccine.
HISTORY OF SHOULDER DYSTOCIA
US for growth at 36 weeks.
Transfer to ANMC at 36 weeks for delivery.
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 Perinatology consultation
Follow plan from ANMC Perinatology note
HISTORY OF SUBSTANCE ABUSE
Discuss at EVERY visit
Monitor for signs or symptoms of abuse
Behavioral Health referral
If opioid, refer to Suboxone clinician
Urine drug screening frequently
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 Bile Acids and LFT 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
BPP weekly after 32 weeks.
Offer induction at 38 weeks.
HIV disease NEW
See Guideline
Contact EIS (907-7292907 or Tiger Text role “ANMC Discharge Scheduler HIV/EIS Clinic”) ASAP for notification and/or medication start
Get initial HIV labs based on recommendations from EIS
Follow HIV in pregnancy Guideline
CD4 count and viral load at 24 and 36 weeks
Refer to Perinatology
See guideline for decision of where to deliver
HIV disease previously known
See Guideline
Continue HAART
Contact EIS (907-7292907 or Tiger Text role “ANMC Discharge Scheduler HIV/EIS Clinic”) for notification and/or medication change
CD4 count and viral load at first prenatal, 24 and 36 weeks
Refer to Perinatology
See guideline for decision where to deliver
HYPERTHYROID prior to pregnancy
Discuss with HROB or OB/GYN at first visit.
Draw TSH, Free T4 at first visit and at least each Trimester.
Redraw TSH and Free T4 4-6 weeks after a dosage change.
Contact Perinatologist to determine need to change Methimazole, change to PTU for first trimester or stop all medications.
If on PTU, continue at present dose.
Monitor for signs and symptoms of hyperthyroid disease at every visit. (goiter, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath)
HYPERTHYROID new diagnosis
Discuss with HROB or OB/GYN at diagnosis or if severe disease suspected.
Draw TSH, Free T4 at first visit and at least each Trimester.
Redraw TSH and Free T4 4-6 weeks after a dosage change.
Observe carefully for signs and symptoms of Thyroid storm. (severe hypertension, goiter, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath)
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. (goiter, tremor, palpitations, anxiety, weight loss despite a normal or increased appetite, increased frequency of bowel movements, and shortness of breath)
HYPOTHYROID prior to pregnancy
Order TSH, Free T4
Do not treat subclinical disease
If previous thyroidectomy or ablation, increase levothyroxine dose by 25% in first trimester and measure TSH and Free T4 every 4-6 weeks until results are stable.
For all others, measure TSH, Free T4 each trimester.
HYPOTHYROID new diagnosis
Begin levothyroxine ASAP at approximately 100mcg daily
Check TSH Free T4 monthly until dosage stable
Check TSH Free T4 every trimester thereafter
Re-evaluate postpartum
INTRAHEPATIC CHOLESTASIS (IHCP) – Severe itching and abnormal Labs
Start ursodiol 600 mg BID. You may increase dose up to 900mg TID for continued severe pruritus.
Start weekly BPP at 32 weeks
Redraw Total Bile Acids (TBA) and LFTs weekly after 32 weeks
May return home with weekly visits
Consult HROB meeting or obstetrician
Correct TBA by subtracting the urodeoxycholic acid (ursodiol) from the TBA on the results.
Severe IHCP if corrected TBA >40, must be induced at 37 weeks in Anchorage.
If corrected TBA > 100, induce at 35-36 weeks in Anchorage.
Mild IHCP, TBA < 40, induce at 38 weeks.
IUGR see Fetal Growth Restriction
LTBI
If prior tuberculosis diagnosis with completed treatment, diagnosis of LTBI.
No PPD or Quantiferon
Ask about symptoms: hemoptysis, fever, night sweats, weight loss, or cough.
If all symptoms are negative, no reactivation of TB and no treatment or diagnostic testing needed.
MIGRAINE HEADACHES
Discontinue triptan medication
Low dose tricyclics OK after 1st trimester
Tylenol.
If above fails, refer to Neurology.
Avoid opiates.
OBESITY
If BMI >40, refer to HROB meeting for consultation.
If BMI >40 and patient 36 weeks gestation or later, Consult HROB on call and on call CRNA on call for consultation regarding suitability for delivery in Bethel.
For all women with BMI> 35, obtain US for growth at 28, 32 and 36 weeks and start BPP weekly at 32 weeks.
POSITIVE ANTIBODY SCREEN
Confirm antibody identification.
If antibody is Kell, Duffy (Fy), c, C, D, e or E, contact OB/GYN or discuss at HROB ASAP
Any other antibody, contact OB/GYN for plan of management.
Obtain Unity cell free DNA screening for T21, T18, T13, sex chromosomes and the antigen identified above. The testing kits are available at the Team Room C nursing station.
If fetal antigen testing is negative, no further testing is needed.
If fetal antigen testing is positive, refer to MFM for plan of care to monitor for isoimmunization.
POSITIVE HIV SCREEN
Confirm HIV status with reflex testing.
Once HIV disease confirmed, see HIV Disease, New
PLACENTAL ABNORMALITIES
LOW LYING: <2.5cm from internal os of the cervix
Repeat transvaginal ultrasound monthly until resolved.
If not resolved by 32 weeks, consult Perinatologist for further plan of management
CIRCUMVALLATE
At risk for growth restriction. Growth US at 32 weeks to assess for growth restriction.
SUCCENTURATE LOBE
Make sure ultrasound has screened for vasa previa
At delivery, ensure entire placenta is removed during 3rd stage.
VELAMENTOUS CORD INSERTION
At risk for growth restriction. Growth US at 32 weeks to assess for growth restriction.
PLACENTA PREVIA
Placenta previa diagnosed at second trimester ultrasound
Repeat ultrasound at 24 weeks.
If still a previa,
Pelvic rest: no sex, no exams
Transfer to Anchorage until previa resolves.
Before 24 weeks, no need to change activity unless actively bleeding
PREDIABETES
Refer patient to Diabetes and prescribe supplies for finger stick testing
Review testing results weekly at HROB rounds with diabetes team
Screen for GDM as per routine care
PREVIOUS CESAREAN
If considering repeat cesarean in Bethel, appointment with OB/GYN ASAP
Refer to HROB meeting for discussion
Repeat Cesareans done in Bethel unless there is a medical reason for the transfer.
Document patient’s choice of location and route of delivery, in note and as comment in diagnosis.
Provide trial of labor after cesarean (TOLAC) education and first prenatal visit.
Complete TOLAC consent ASAP
Rh negative
See Guideline.
Repeat Type and Screen with Rhogam work up at 28 weeks.
If RH negative, Give Rhogam at 28 weeks.
At delivery, follow OB guideline for Rh negative patients.
RUBELLA NON-IMMUNE
Repeat MMR vaccine postpartum if the patient has fewer than 3 lifetime MMR vaccines
SHORT CERVIX ON SCREENING
History of Preterm Birth
Cervical length less than 25mm
Consult with MFM provider to discuss cerclage
Cervical length 26 to 29mm
Weekly cervical length ultrasound
Cervical length 30mm, continue every other week cervical length measurements until 24 weeks.
No History of Preterm Birth
Cervical length 20mm or less
Vaginal progesterone 200mg qhs
Repeat cervical length in 1-2 weeks
Cervical length 10mm or less
Consult MFM or OBGYN for possible cerclage
SUBOXONE TREATMENT
Make appointments with Dr Compton or another MAT/Women’s Health (WH) provider
UDS as needed (does not need to be every week), Tramadol and/or gabapentin levels depending on patient’s drug use history
Transfer to Anchorage at 36 weeks or sooner for delivery
TWIN GESTATION (Diamniotic-Dichorionic)
Add Folic Acid 1mg daily
Aspirin 162mg daily from 12 weeks until delivery
18 Weeks ANMC
TV ultrasound for cervical length
Early DAFUS,
Counseling
22 Weeks ANMC
Full DAFUS
24 Weeks YKHC
Prenatal visit
1 hr. GST, CBC
26 Weeks YKHC
Prenatal visit
Ultrasound for fetal growth and TV ultrasound for cervical length
28 Weeks YKHC
Prenatal visit
30 Weeks YKHC
Prenatal visit
Ultrasound for fetal growth and TV ultrasound for cervical length
** BE IN BETHEL due to high risk pregnancy **
31 Weeks YKHC
Prenatal visit
32 Weeks YKHC
** Transfer to ANMC until delivery**
TWIN GESTATION MONOAMNIOTIC-DICHORIONIC OR MONOAMNIOTIC-MONOCHORIONIC
Add Folic Acid 1mg daily
Aspirin 162mg daily from 12 weeks until delivery
16 weeks – Appointment in Anchorage to evaluate for twin-twin transfusion syndrome
All future appointments in Anchorage
UTERINE SHELF
Repeat ultrasound in 4 weeks.
These rarely are a problem
UTI IN PREGNANCY
Urine Culture every visit
Prophylaxis after 2nd UTI or 1st pyelonephritis: recommend Nitrofurantoin 100mg po qhs.
TOLAC in Bethel, Planned
Discuss Case at HROB meeting
At BIB, provider will contact the HROB on call, blood bank lead, OB charge nurse.
On admission in labor: Admitting physician will notify CRNA on call, HROB on call.
Complete TOLAC Consent at earliest prenatal visit possible
VITAMIN D DEFICIENCY
SELECT ONLY ONE SENTENCE FOR NOTE
25-OH Vitamin D > 20ng/ml Continue cholecalciferol 1000 IU daily (standard for all patients)
25-OH Vitamin D > 12ng/ml and <20ng/ml increase cholecalciferol to 3000 IU daily
25-OH Vitamin D < 12ng/ml
If < 32 weeks, increase cholecalciferol to 3000 IU daily
If > 32 weeks give ergocalciferol 50,000 IU weekly for 12 weeks.
