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Prenatal Care - Adult/Pediatric - Ambulatory Clinical Practice Guideline

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1
Prenatal Care – Adult/Pediatric – Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click each header below to jump to the section of interest
Table of Contents
INTRODUCTION .................................................................................................................................4
SCOPE ................................................................................................................................................4
RECOMMENDATIONS .........................................................................................................................4
Entry of prenatal care ....................................................................................................................................... 4
Pregnancy dating .................................................................................................................................................. 4
Documenting patient’s pre-gravid weight ............................................................................................................ 4
Frequency of prenatal care visits .......................................................................................................................... 5
Initial Visit with Provider (Target 6-12 weeks).................................................................................................. 5
Patient history ....................................................................................................................................................... 5
Medication history ................................................................................................................................................ 6
Physical examination ............................................................................................................................................ 6
Gestational weight gain ........................................................................................................................................ 6
Fetal heart rate ..................................................................................................................................................... 7
Lifestyle considerations during pregnancy ............................................................................................................ 7
Infections and diseases screening .................................................................................................................... 8
Asymptomatic bacteriuria..................................................................................................................................... 8
Sexually transmitted diseases ............................................................................................................................... 8
Hepatitis B Virus (HBV).......................................................................................................................................... 8
Hepatitis C virus (HCV) .......................................................................................................................................... 9
Group B Streptococcus .......................................................................................................................................... 9
Maternal medical conditions screening ......................................................................................................... 10
Preeclampsia ....................................................................................................................................................... 10
Anemia ................................................................................................................................................................ 10
Antibody testing .................................................................................................................................................. 10
Gestational diabetes ........................................................................................................................................... 11
Initial visit with provider – Special populations .............................................................................................. 11
Chronic hypertension .......................................................................................................................................... 11
Hypothyroidism ................................................................................................................................................... 11
Obese patients .................................................................................................................................................... 12
History of gestational diabetes ........................................................................................................................... 13
Previous preterm labor (i.e., spontaneous delivery before 37 weeks gestation) ................................................ 13
Aneuploidy/Open Neural Tube Defects Screening Options ........................................................................... 14
Aneuploidy/Open neural tube defects screening discussion ............................................................................... 14
Table 7. Detection rates and pregnancy risks involved with select prenatal screening interventions ................ 15
Table 8. Advantages and Disadvantages of Aneuploidy and Open Neural Tube Defect Screening Options ....... 16
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Carrier Screening for Genetic Disorders ......................................................................................................... 17
Discussion of Genetic Carrier Screening .............................................................................................................. 17
Cystic Fibrosis ...................................................................................................................................................... 17
Spinal Muscular Atrophy ..................................................................................................................................... 17
Hemoglobinopathies ........................................................................................................................................... 18
Fragile X Syndrome ............................................................................................................................................. 18
Tay - Sachs disease .............................................................................................................................................. 19
Genetic Diseases in Patients of Ashkenazi Jewish Descent ................................................................................. 19
Expanded Carrier Screening ................................................................................................................................ 19
Immunizations in pregnancy .......................................................................................................................... 20
Influenza vaccination .......................................................................................................................................... 20
Tetanus, diphtheria and pertussis vaccination (Tdap) ........................................................................................ 20
Labor considerations and planning ................................................................................................................ 20
Confirm vertex presentation ............................................................................................................................... 20
Trial of labor after cesarean delivery (TOLAC) discussion ................................................................................... 20
Herpex simplex virus (HSV) suppression.............................................................................................................. 20
Antepartum Fetal Surveillance ....................................................................................................................... 21
Table 9. Common Indications for Antepartum Fetal Surveillance ....................................................................... 21
Depression in Pregnancy ................................................................................................................................ 22
Screening for depression in pregnancy (12 years or older) ................................................................................. 22
Follow-up Plan Documentation ........................................................................................................................... 23
Treatment of depression in pregnant patient (12 years or older) ....................................................................... 23
Patient education on depression ......................................................................................................................... 24
METHODOLOGY ............................................................................................................................... 25
COLLATERAL TOOLS & RESOURCES ................................................................................................... 28
APPENDIX A. OVERVIEW OF PRENATAL CARE .................................................................................... 30
APPENDIX B. DEPRESSION IN PREGNANCY ALGORITHM .................................................................... 32
APPENDIX C. PHARMACOTHERAPY OPTIONS FOR PERINATAL DEPRESSION ....................................... 33



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3

Content Expert(s):
Name: Cynthia Anderson, MD – Obstetrics and Gynecology
Phone Number: (608) 287-5807
Email Address: ckanderson@wisc.edu

Name: Michelle Bryan, MD – Family Medicine
Phone Number: (608) 222-8779
Email Address: michelle.bryan@uwmf.wisc.edu

Contact for Changes:
Name: Katherine Le, PharmD – Center for Clinical Knowledge Management
Phone Number: (608) 890-5898
Email Address: kle@uwhealth.org

Workgroup Members:
Laura Birkeland, CGC – Pediatrics
William Cunningham, MD – Swedish American (Obstetrics and Gynecology)
Wayne Evans, MD – Swedish American (Maternal Fetal Medicine)
Monica Stone- RN – Swedish American (Nursing)
Jodi Wagner, CNM – Midwife Service

Reviewer(s):
J. Igor Iruretagoyena, MD – Maternal Fetal Medicine
David Yang, MD – Laboratory

Committee Approval(s):
Clinical Knowledge Management (CKM) Council (12/21/17)















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4

Introduction
Prenatal care is important in promoting a healthy pregnancy and a health birth. This guideline
provides evidence-based recommendations for prenatal care on topics such as screening for
genetic anomalies, gestational weight gain, immunizations, and diagnosis and management of
gestational diabetes. This guideline incorporates recommendations from the US Preventive
Services Task Force and other national organizations/societies such as the American Congress
of Obstetricians and Gynecologists.
Scope
Intended User(s): Physicians, Advanced Practice Providers, Registered Nurses, Certified
Nurse Midwives, Genetic Counselors

Objective(s): To provide evidence-based recommendations regarding prenatal care for UW
Health patients in the ambulatory setting

Target Population: Pregnant adolescent and adult patients

Clinical Questions Considered:
• What laboratory tests are recommended for all pregnant patients during the first
trimester?
• What laboratory tests are recommended during the initial prenatal visit for patients with
hypertension, diabetes, hypothyroidism and/or obesity?
• What are common prenatal screening options for patients?
• What are considerations for carrier screening in pregnant patients?
• When and how should patients be screened for gestational diabetes?
• What are common indications for antepartum fetal surveillance?
Recommendations

Entry of prenatal care
Pregnancy dating
Upon initial notification by the patient regarding confirmed pregnancy by home testing, it is
recommended to obtain and document the patient’s last reported menstrual period. (UW Health
Low quality evidence, strong recommendation.) If dating is uncertain, patient may be offered a
dating ultrasound which should occur at approximately 7-8 weeks of pregnancy. The dating
ultrasound should not be scheduled prior to 6 weeks of pregnancy.
1
(UW Health Low quality
evidence, strong recommendation.)
Documenting patient’s pre-gravid weight
It is important to establish a patient’s pre-gravid weight to determine what appropriate
gestational weight gain will be for the pregnancy. A patient’s pre-gravid weight should be
documented in the medical chart as outlined in Figure 1. (UW Health Low quality evidence, strong
recommendation.)

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5

Figure 1. Pre-gravid weight recording algorithm

Frequency of prenatal care visits
It is recommended that patients who are of average risk should be seen initially by the prenatal
care provider between 6-12 weeks gestation. There after, the frequency of visits should occur
on the following schedule:
2
(UW Health Low quality evidence, strong recommendation.)
• Every 4-6 weeks through 28 weeks gestation
• Every 2-3 weeks through 36 weeks of gestation and
• Every week thereafter

Initial Visit with Provider (Target 6-12 weeks)
Patient history
It is recommended to document patient’s medical history that is relevant to the current
pregnancy, including obstetrical history (e.g., history of operative or preterm deliveries,
gestational diabetes) and any chronic medical conditions (such as history of hypertension or
hypothyroidism.) (UW Health Low quality evidence, strong recommendation.) If the patient is
diabetic and is not currently seeking obstetric care from Obstetrics/Gynecology, it is
recommended that the patient be referred to Obstetrics. (UW Health Low quality evidence, strong
recommendation.)
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Medication history
It is recommended to obtain and document patient’s current medication list, including whether or
not patient is currently taking a prenatal vitamin. If the patient is not taking a prenatal vitamin,
the patient may be offered a prescription for a prenatal vitamin. (UW Health Low quality evidence,
strong recommendation.)

Folic Acid
A daily supplement of folic acid containing 0.4 to 0.8 mg of folic acid is recommended for all
patients planning or capable of pregnancy.
3
(USPSTF Grade A) Women at increased risk for a
pregnancy with a neural tube defect (i.e., history of a prior child with a neural tube defect or
family history of neural tube defect) should be offered a higher dose of folic acid
supplementation (4 mg daily) beginning 1 month before trying to conceive and continuing
through the first 3 months of pregnancy.
3,4
(UW Health Low quality evidence, strong
recommendation)

Note: Folic acid supplementation should not be achieved by taking multiple vitamins, due to the
risk of vitamin A toxicity.
Physical examination
A routine physical examination, including a pelvic examination which may detect reproductive
tract abnormalities, is recommended during the initial visit with the prenatal care provider.
1
(UW
Health Low quality evidence, strong recommendation.)
Gestational weight gain
It is recommended to measure a patient’s weight at each prenatal visit
1
and that providers
discuss what appropriate gestational weight gain is with the patient.
5,6
(UW Health Low quality
evidence, strong recommendation)

The Institute of Medicine guidelines (Table 1) outline the recommended maternal weight gain,
based upon the patient’s pre-pregnancy body mass index (BMI).
5,7


Table 1. Weight Gain Recommendations for Pregnancy
Prepregnancy
Weight Category
BMI
Recommended
Total Weight
Gain Range
(lbs.)
Recommended Rates of
Weight Gain Second and
Third Trimesters (mean
range, lb./week)
Recommended
Total Weight
Gain Range (lbs.)
Single Fetus Single Fetus Twins
Underweight
Less than
18.5
28-40 1 (1-1.3) --
Normal weight 18.5-24.9 25-35 1 (0.8-1) 37-54
Overweight 25.0-29.9 15-25 0.6 (0.5-0.7) 31-50
Obese
(includes all classes)
≥ 30.0 11-20 0.5 (0.4-0.6) 25-42


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Fetal heart rate
It is recommended to auscultate for fetal heart rate at each prenatal visit to confirm viable fetus
starting at approximately 10 weeks gestation.
1,8
(UW Health Low quality of evidence, strong
recommendation)
Lifestyle considerations during pregnancy
It is important to counsel pregnancy patients on lifestyle considerations such as diet, exercise,
smoking cessation, alcohol use, and hot tubs and saunas use.
1
(UW Health Very Low quality
evidence, strong recommendation) Table X provides a select list of lifestyle topics in pregnancy to
counsel on.

Table 2. Lifestyle considerations in pregnancy
Topic Counseling points
Caffeine
9,10

• Limit caffeine consumption to less than 200 mg per day
Diet
1

• Avoid unpasteurized products (e.g., soft cheese),
delicatessen foods, pate and raw eggs.
• Avoid seafood with high levels of mercury (e.g., swordfish,
tuna steaks, mackerel) and raw fish/shellfish
Tobacco use/smoking
cessation
11

• Counsel current patients who smoke on risks of tobacco
use in pregnancy such as miscarriage, premature birth,
low birth weight, increased risk for sudden infant death
syndrome (SIDS)
Alcohol use
12,13

• Recommend to avoid alcohol consumption during
pregnancy; no amount of alcohol consumption has been
proven safe in pregnancy
Dental care
14

• Counsel patients susceptibility to oral disease such as
periodontal disease and association of periodontal disease
and adverse pregnancy outcomes (i.e., premature birth,
low birth weight)
• Advise patient to practice dental hygiene and seek
standard dental care evaluation
Exercise
1

• Encourage physical activity as at least 30 minutes of
exercise on most days of the week is reasonable
Hot tubs and saunas
1

• Advise patients to avoid hot tubs and saunas during first
trimester because heat exposure has been associated
with neural tube defects and miscarriage
Over the counter medications
1

• Counsel patients on common OTC medications that are
safe to use in pregnancy (i.e., acetaminophen for pain,
antacids for acid reflux) and what medications should be
avoided



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8

Infections and diseases screening
Asymptomatic bacteriuria
Pregnant women should be screened for asymptomatic bacteriuria with urine culture at 12-16
weeks of gestation or at their first prenatal visit if later.
15
(USPSTF Grade A) A urine culture is
sufficient for detecting asymptomatic bacteriuria and thus a urinalysis does not need to be
ordered at the same time. If the urine culture is positive, the patient should be treated with
appropriate antibiotic therapy.
16
(IDSA A-I)
Sexually transmitted diseases
Syphilis
It is recommended that all pregnant patients be screened for syphilis at the first prenatal visit. If
the patient is at high risk, the patient should be retested early in the third trimester and at
delivery.
17
(UW Health Low quality evidence, strong recommendation.) This recommendation is
consistent with what is recommended by the Centers for Disease Control and Prevention
(CDC).

In Illinois, healthcare providers are required by law to screen all pregnant patients for syphilis
infection during the first prenatal visit and during the third trimester. If any blood test shows a
positive or inconclusive result, an additional test or tests should be performed. An infant cannot
be discharged from the hospital unless the syphilis status of the mother has been determined at
least once during the course of pregnancy and preferably again at delivery.

Chlamydia and Gonorrhea
It is recommended that all prenatal patients be screened for chlamydia/gonorrhea during the
first prenatal visit. (UW Health Low quality of evidence, weak/conditional recommendation) This
recommendation is consistent with the Illinois Department of Public Health. The CDC
recommends that all pregnant patients < 25 years of age and pregnant patients >25 years of
age who are at increased risk of infection be screened for chlamydia and gonorrhea. These
patients should also be retested for chlamydia infection during the third trimester.
17


Pregnant patients with chlamydial infection should have a test of cure 3-4 weeks after treatment
and be retested within 3 months. Pregnant patients with gonorrhea infection should be retested
3 months after treatment.
17
(UW Health Low quality of evidence, strong recommendation)

Human Immunodeficiency Virus (HIV)
It is recommended to screen all pregnant patients for Human Immunodeficiency virus during the
first prenatal visit.
18-20
(USPSTF A)

Per Illinois law, newborns must be screened for HIV if the mother’s HIV status is unknown. For
patients who are at high risk for infection, it is recommended to retest in the third trimester.
17

Hepatitis B Virus (HBV)
It is recommended that all pregnant patients be screened for Hepatitis B surface antigen
(HBsAg) during the first prenatal visit of each pregnancy, even if they have been previously
vaccinated or tested.
8,21
Any pregnant patient who was not screened prenatally and any
pregnant patient at high risk for Hepatitis B infection should be tested upon admission for
delivery. (UW Health Low quality of evidence, strong recommendation)

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Patients who may be at high risk for Hepatitis B include persons born in countries with ≥ 2%
prevalence of HBV, persons who inject drugs, HIV-positive, household and sexual contact with
HBV-infected persons, individuals requiring immunosuppressive therapy, end stage renal
disease patients, U.S born persons not vaccinated as infants whose parents were born in
regions with a high prevalence of HBV infection (≥8%) such as sub-Saharan Africa and Central
and Southeast Asia.
22,23


Hepatitis C virus (HCV)
It is recommended to screen for Hepatitis C virus in pregnant patients with risk factors for
Hepatitis C (see Table 3) at the first prenatal visit.
17
(UW Health Low quality of evidence,
weak/conditional recommendation)

Table 3. Criteria for who should receive prenatal screening for Hepatitis C virus
17,24-26

• Injectable illegal drug use (even if only used once)
• Long-term hemodialysis
• Percutaneous/parenteral exposures in unregulated setting (e.g., tattoo received outside of
licensed parlors or medical procedures done in settings without strict infection control policies)
• Recipients of transfusions or organ transplantation before July 1992
• Recipients of clotting factor concentrates produced before 1987
• Recipients of blood products from donor who later tested positive for HCV
• History of incarceration
• Seeking care or evaluation for sexually transmitted infection (including HIV)
• Unexplained chronic liver disease, including persistent elevated alanine aminotransferase (ALT)
• Born to an HCV-infected mother
• Patients born between 1945-1965
Group B Streptococcus
Group B Streptococcus (GBS) can be especially severe for newborn infants causing potentially
sepsis, pneumonia or even meningitis. Group B strep can be passed from mother to infant
during labor thus screening is vital for preventing infection.

The CDC recommends that all pregnant patients be screened for GBS disease by obtaining a
vaginal-rectal swab specimen at 35-37 weeks gestation.
6,27,28
(CDC Grade AII) If the patient had
a previous positive GBS culture during the current pregnancy (e.g., urine culture) or who had a
previous infant with invasive GBS disease and received intrapartum antibiotic prophylaxis, a
third trimester vaginal swab screen is not necessary/recommended.
29
(CDC Grade AII)

If the patient’s GBS status is unknown at the onset of labor or preterm rupture of membranes
occurs before 37 weeks gestation with a substantial risk for preterm delivery, then GBS
screening should be performed and intrapartum antibiotic prophylaxis should be provided
pending culture results (unless a vaginal-rectal GBS screen was performed within the preceding
5 weeks).
28
(CDC Grade AII)

The following CDC algorithms
28
may be used as reference:
• GBS Screening/Intrapartum Prophylaxis (Preterm labor) Algorithm
• GBS Screening/Intrapartum Prophylaxis (Preterm Premature Rupture of Membranes)
Algorithm
• Intrapartum Antibiotic Prophylaxis Regimens Algorithm
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10

Maternal medical conditions screening
Preeclampsia
Preeclampsia is diagnosed when there is a systolic blood pressure (BP) ≥ 140 mm Hg or a
diastolic BP ≥90 on at least two occasions, taken at least four hours apart plus new-onset
proteinuria (≥ 300 mg protein in 24-hr urine sample or urinary protein/creatinine ration ≥0.3)
and/or one of the following severe features:
30,31

• Elevated blood pressure (systolic ≥ 160 mm HG, diastolic ≥ 110 mm Hg)
• Elevated creatinine level (> 1.1 mg/dL or ≥ 2 times baseline)
• Hepatic dysfunction (transaminase levels ≥ 2 times upper limit of normal) or right-upper
quadrant or epigastric pain
• New onset headache or visual disturbances
• Thrombocytopenia (Platelet count < 100,000/ µL)
• Pulmonary edema

According to the U.S Preventive Services Task Force, it is recommended that all pregnant
individuals without a known diagnosis of preeclampsia or hypertension be screened for
preeclampsia. (USPSTF Grade B) Blood pressure measurement is routinely used for screening
and should be measured while the patient is relaxed, quiet and in a sitting position with legs
uncrossed and back supported.
32


For women who are at high risk for preeclampsia, low-dose daily aspirin (i.e., 81 mg daily) is
recommended after 12 weeks of gestation.
32
(USPSTF Grade B) Increased risk for preeclampsia
include a history of eclampsia or preeclampsia (particularly early-onset preeclampsia), previous
adverse pregnancy outcome, maternal comorbid conditions such as diabetes or chronic
hypertension, multifetal gestation, African-American race, low-socioeconomic status and
advanced maternal age.
32

Anemia
Iron deficiency anemia in pregnancy has been associated with an increased risk of low birth
weight, preterm delivery, and perinatal mortality.
33
Screening for iron deficiency may be initiated
upon initial notification of pregnancy to clinic.
3,33-35
(USPSTF Grade B) Anemia screening should
involve a hematocrit or hemoglobin test. (USPSTF Grade B) Repeat testing may be done again
between 24-28 weeks gestation using a hematocrit or hemoglobin test.
36
(UW Health Low quality
evidence, weak/conditional recommendation)
Antibody testing
All pregnant women should be tested for ABO blood group (Rh-D type) and screened for the
presence of erythrocyte antibodies (type and screen) during the first prenatal visit.
3,6,35,37,38

(USPSTF Grade A)

Antibody testing should be repeated in un-sensitized Rh (D)-negative patients at 24-28 weeks of
gestation, unless the biological father is known to be Rh (D)-negative.
38
(USPSTF Grade B)
Patients who are un-sensitized D-negative should receive prophylactic anti-D immunoglobulin
(RhoGAM 300 mcg) at 28 weeks, or at the time of any of the following
3,6,37
:
- Ectopic gestation
- Abortion (threatened, spontaneous or induced)
- Procedures associated with possible fetal-to-maternal bleeding, such as chorionic villus
sampling or amniocentesis
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- Conditions associated with fetal-maternal hemorrhage (i.e., abdominal trauma)
- Unexplained vaginal bleeding during pregnancy
- Delivery of a newborn who is D-positive

Testing should be completed prior to immunoglobulin (RhoGAM) administration.
37
(UW Health
Low quality of evidence, strong recommendation)
Gestational diabetes
The American College of Obstetricians and Gynecologists (ACOG) recommend that all pregnant
individuals be screened for gestational diabetes mellitus (GDM). Screening should ideally occur
between 24 and 28 weeks of pregnancy. It is recommended that all pregnant patients be
screened for GDM with a 50 gram (non-fasting) oral glucose challenge test (OGTT) with plasma
glucose measurement at 1 hour.
39
(UW Health Moderate quality of evidence, strong recommendation)

If the plasma glucose level measured at 1 hour is ≥ 140 mg/dL, a 100 gram three-hour OGTT
should be performed when the patient has fasted.
39
(UW Health Low quality of evidence, strong
recommendation) Gestational diabetes is diagnosed if 2 or more plasma glucose measurements
(measured fasting, 1 hr, 2 hr, 3 hr after OGTT) listed in Table 4 are met or exceeded.
40


Table 4. Diagnostic values for Gestational Diabetes in 100 gram OGTT test

Carpenter/Coustan
Pre-OGTT Fasting 95 mg/dL
Hours after
OGTT
1 hour 180 mg/dL
2 hour 155 mg/dL
3 hour 140 mg/dL

Initial visit with provider – Special populations
Chronic hypertension
The following laboratory tests are recommended to be obtained during the first prenatal visit for
any pregnant patient with chronic hypertension or a history of a hypertensive order of pregnancy
(e.g., preeclampsia):
31,41
(UW Health Low quality of evidence, strong recommendation)
• Baseline measure of creatinine
• Baseline measure of uric acid
• Baseline liver AST/ALT
• Baseline protein creatinine ratio

It is advised that providers counsel patients on taking low-dose daily aspirin (81 mg/daily) after
12 weeks gestation to prevent preelampsia.
32
(USPSTF Grade B)
Hypothyroidism
A Thyroid-stimulating hormone (TSH) and a free thyroid hormone-4 (T4) level are typically
needed to appropriately diagnose thyroid disorder/condition (i.e., over hypothyroidism,
subclinical hyperthyroidism, hypothyroxinemia.)
42
Therefore, it is recommended that at the first
prenatal visit, patients with hypothyroidism have their TSH and T4 levels checked. (UW Health
Moderate quality of evidence, strong recommendation)

Between 50-85% of hypothyroid patients will require an increased in levothyroxine dosing during
pregnancy. It is recommended that pregnant patients with hypothyroidism be advised that
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12

thyroid dose adjustments will likely be needed throughout the first trimester. (ATA Strong
recommendation, high quality evidence)

The American Thyroid Association recommends that levothyroxine dose be adjusted by
approximately 20-30% upon confirmation of pregnancy (i.e., positive home pregnancy test)
however providers may choose to increase dose/adjust medication based on TSH and free T4
levels at the first prenatal visit.
42,43


Pregnant patients with hypothyroidism or at risk for hypothyroidism should be monitored with a
serum TSH measurement every 4 weeks until midgestation (~20 weeks) and at least once near
30 weeks gestation.
43
(ATA Strong recommendation, high quality evidence)

If trimester-specific reference ranges for TSH are not available in/per the laboratory, the
following reference ranges may be used:
44
(UW Health Moderate quality of evidence,
weak/conditional recommendation)
• 0.1-2.5 mIU/L for first trimester
• 0.2-3.0 mIL/L for second trimester
• 0.3 -3.0 mIL/L for third trimester
Obese patients
Obesity is a risk for gestational hypertension, preeclampsia and gestational diabetes.
Congenital malformations including cardiac defects and neural tube defects are more common
among obese pregnant patients.
45
Patients who meet criteria listed in Table 5 should be
managed for consideration of maternal obesity.
41


Table 5. Criteria for consideration of maternal obesity
• Patients with a body mass index ≥30 kg/m
2
(i.e., obese)
• Patients with a body mass index ≥25 kg/m
2
(i.e., overweight) with one of the following risk factors:
o Family history of Type 2 Diabetes (i.e., 1
st
degree relative)
o History of gestational diabetes
o History of macrosomic infant
o History of glucose intolerance
o Polycystic Ovarian Syndrome (PCOS)
o Metabolic disorder
o Hypertension
o Hyperlipidemia
o Chronic systemic steroid use

For patients with BMI > 35 kg/m
2
, consider recommending use of 5 mg folic acid up to 12 weeks
to reduce risk of neural tube defects.
46,47
(UW Health Moderate quality of evidence, weak/conditional
recommendation)

The following labs should be obtained during the initial prenatal visit: (UW Health Low quality of
evidence, strong recommendation)
48

• A1 c measurement (if not already ordered)
• Baseline measure of creatinine
• Baseline measure of uric acid
• Baseline AST/ALT
• Baseline protein creatinine ratio

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13

During the initial prenatal care visit, a referral to Nutrition may be offered to the patient too.
46,47

(UW Health Low level of evidence, strong recommendation)

Table 6 lists labs and suggested additional interventions depending on the pregnant patient’s
BMI.
45-47,49,50
(UW Health Low quality of evidence, strong recommendation)

Table 6. Labs and additional interventions for pregnant obese patient
BMI > 25-29 kg/m
2
with at
least 1 additional risk
factor
BMI 30-39 kg/m
2
BMI ≥ 40 kg/m
2

• A1 c measurement (if
not already ordered)
• Baseline measure of
creatinine
• Baseline measure of
uric acid
• Baseline AST/ALT
• Baseline protein
creatinine ratio

• A1 c measurement (if not
already ordered)
• Baseline measure of
creatinine
• Baseline measure of uric
acid
• Baseline AST/ALT
• Baseline protein
creatinine ratio

• Consider 5 mg folic acid
• A1 c measurement (if not already
ordered)
• Baseline measure of creatinine
• Baseline measure of uric acid
• Baseline AST/ALT
• Baseline protein creatinine ratio
• Consider 5 mg folic acid
• Screen for sleep apnea
• Consider/order ECHO
• Refer to anesthesia for consult
History of gestational diabetes
Any patient with a history of diabetes, gestational diabetes or a history of macrosomic
pregnancy (i.e., birthweight > 4000 grams or birthweight) is considered at risk for gestational
diabetes in current pregnancy. Additional risk factors for GDM include:
39,40,47

• BMI > 30
• First or second degree relative with type 2 diabetes
• BMI > 25 and one other risk factor (i.e., history of glucose intolerance defined as A1c >
5.7% or fasting plasma glucose > 100 mg/dL)
• High risk race/ethnicity (e.g., Native American, African American, Latino, Asian
American, Pacific Islander)
• Signs of insulin resistance or conditions associated with insulin resistance (acanthosis
nigricans, hypertension, dyslipidemia, polycystic ovarian syndrome, or small-for-
gestational-age birthweight)

If the patient is willing, a fasting glucose test is recommended. However, if the patient is unable
to do fasting glucose test, it is strongly recommended to obtain an A1c measure, if one has not
been already ordered.
39,40,47
(UW Health Low quality of evidence, strong recommendation)
Previous preterm labor (i.e., spontaneous delivery before 37 weeks gestation)
• It is recommended that a patient with a singleton gestation and prior spontaneous
preterm birth be offered progesterone supplementation starting at 16-20 weeks of
gestation.
51
(UW Health Moderate quality of evidence, strong recommendation)
o 250 mg of 17-alpha-hydroxy-progesterone (17-OHPC) weekly
52

• Vaginal progesterone is recommended as a preterm labor management option in
asymptomatic patients without a previous preterm birth delivery who are identified with
short cervical length (≤20 mm) before or after 24 weeks of gestation.
51
(UW Health
Moderate quality of evidence, strong recommendation)
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14

o Suggested dosing: vaginal progesterone (200 mg or 90 mg gel) nightly starting
by 24 weeks until 36 6/7 weeks
52


For pregnant patients between 24-34 weeks of gestation who are at risk of delivery within 7
days, a single course of corticosteroids is recommended.
53
(UW Health Moderate quality of
evidence, strong recommendation)

Aneuploidy/Open Neural Tube Defects Screening Options
Aneuploidy/Open neural tube defects screening discussion
It is recommended that all pregnant patients be offered aneuploidy screening or diagnostic
testing, regardless of maternal age.
54
(UW Health Very low quality evidence, strong recommendation)
Screening for aneuploidy should be an informed patient choice. All providers should be familiar
with the available screening and testing options and have a standard approach to counseling
women, ideally at the initial provider visit.
55
The most common prenatal screening options are:
first trimester screen (i.e., nuchal translucency), maternal serum alpha fetoprotein (MS-AFP)
screen, Quad screen, 20 week ultrasound and Non-invasive prenatal testing (i.e., cell free DNA
testing.) The most common diagnostic tests done are chorionic villus sampling (CVS) and
amniocentesis. Table 7 outlines detection rates and pregnancy risks involved with these
screening and diagnostic tests while Table 8 lists advantages and disadvantages to consider.

“No one screening test is superior to other screening tests in all test characteristics. Each test
has relative advantages and disadvantages. It is important that obstetrician–gynecologists and
other obstetric care providers be prepared to discuss not only the risk of aneuploidy but also the
benefits, risks, and limitations of available screening tests.”
55
Patients should also be advised
that not all screening options may be covered by insurance without prior authorization. For
example, NIPT is often covered one pre-authorization has been obtained for patients who meet
the following criteria:
• Maternal age 35 years or older at delivery;
• Fetal ultrasonographic findings indicating an increased risk for aneuploidy;
• History of a prior pregnancy with a trisomy;
• Positive test results for aneuploidy, including first trimester, sequential, integrated or
quad screen;
• Parental balanced robertsonian translocation with increased risk for fetal trisomy 13 or
21).
56


Women with an abnormal screening test should be offered diagnostic testing and if feasible, a
referral to genetic counselor should be considered or offered.
54
(UW Health Low quality of
evidence, strong recommendation) A negative screening test does not rule out the disease that
was screened.

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Table 7. Detection rates and pregnancy risks involved with select prenatal screening interventions

Screening Diagnostic

First Trimester
Screen
57-64

Quad Screen
65-73
AFP
65

20 Week
Ultrasound
74

NIPT
75-78
CVS
79

Amniocentesis
79

Timing
11 4/7-13 6/7
weeks
(IRA- blood 9 0/7)
15 – 22 6/7 weeks
15 – 22 6/7
weeks
20 weeks > 9-10 weeks
11 4/7 – 13 6/7
weeks
> 15-16 weeks
Detection
Rates:
Aneuploidy
Trisomy 21: 91-
95%
Trisomy 18: 95%
Trisomy 13: 95%

(False Positive 2%)
Trisomy 21: 77-81%
Trisomy 18: 60-80%
Trisomy 13: N/A

(False Positive 6-7%)
N/A
Trisomy 21: 50%
Trisomy 18: 75%
Trisomy 13: 80%

(False Positive 11-
17%)
Trisomy 21: 99%
Trisomy 18: 99%
Trisomy 13: 91%
Other

(False Positive
0.5%)
> 99% > 99%
Detection
Rates:
Open Neural
Tube Defects
(ONTD)
ONTD: N/A
Anencephaly: 90%
80% 80%
ONTD: 95%
Anencephaly: 99%
N/A N/A 98-99%
Pregnancy
Risks
None None None None None
0.1%-0.3%
(1/1000 –
1/300)
0.1%-0.3%
(1/1000 – 1/300
Turn around
time (TAT)
5-7 days
IRA- Same day as
U/S
4-6 days 3 days Same day
6-10 days
Phone Call
10-14 days
Phone Call
7-10 days
Phone Call
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16

Table 8. Advantages and Disadvantages of Aneuploidy and Open Neural Tube Defect Screening Options
Test Advantages Disadvantages
N
o
n
-
i
n
v
a
s
i
v
e

Cell free DNA
screening
• Screens for Trisomy 21, 18, 13, sex chromosome
aneuploidy, +/- microdeletions or triploidy (depending
on company)
• No risk to pregnancy
• Early (9-10 weeks)
• Among screening tools:
• Highest detection rates (91-99%)
• Lowest false positive rates (1% or less)
• Easy – blood only (can be done at PCP office but at
this time many pts referred to genetic counselor)
• TAT: 6-10 days
• Not Diagnostic
• Limited insurance coverage, policies & plans vary
• Only specific trisomies, +/- microdeletion
syndromes
• Different testing companies with different
platforms & costs
• Not consistent detection rates across diseases
• New technology, potential lack of understanding
among patients and providers
• Possible no results due to low fetal fraction
First Trimester
Screening
(FTS)
• Screens for Trisomy 21, 18, 13 (T13 +/- depending on
lab)
• No risk to pregnancy
• Early (12-14 weeks)
• High detection (91-95%)
• Quick (TAT ~ 3-5 days)
• Not Diagnostic
• Requires referral to certified center
• False positives (2-5%)
• Does not screen for open neural tube defects
(ONTD)

Quad • Screens for Trisomy 21, 18
• No risk to pregnancy
• Screens for ONTD
• Easy – blood only in PCP office
• TAT: 4-6 days
• Not Diagnostic
• Highest false positives compared to FTS & NIPT
• Later in pregnancy (>15-16 weeks)
I
n
v
a
s
i
v
e

Chorionic
Villus Sampling
(CVS)
• Diagnostic (>99%)
• Tests for all aneuploidy (polyploidy)
• Test for other chromosome anomalies (e.g.
translocations)
• Test for other genetic diseases as indicated
• Early (12-14 weeks)
• TAT 10-14 days (if available, prelims in 48 hours)
• Risk of miscarriage or complication
• Does not test for ONTD
• Mosaicism
• Possible no results due to low sample size

Amniocentesis • Diagnostic (>99%)
• Tests for all aneuploidy (polyploidy
• Test for other chromosome anomalies (e.g.
translocations)
• Test for other genetic diseases as indicated
• Tests for ONTD (98%)
• TAT: 7-10 days (if added on, FISH 48 hours)
• Risk of miscarriage or complication
• Later in pregnancy (>15-16 weeks)




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Carrier Screening for Genetic Disorders
Discussion of Genetic Carrier Screening
It is recommended that the prenatal care provider review carrier screening options for genetic
disorders, ideally prior to pregnancy, or at the initial provider visit. (UW Health Low quality
evidence, weak/conditional recommendation) All patients, “regardless of screening strategy and
ethnicity, should be offered carrier screening for cystic fibrosis and spinal muscular atrophy, as
well as a complete blood count and screening for thalassemias and hemoglobinopathies.”
Carrier screening for other diseases may be considered based on family or medical history and
ethnicity.
80
Providers should be aware that patients may decline any or all carrier screening.
Genetic carrier screening for a specific disease typically does not need to be repeated with
subsequent pregnancies. It is recommended a patient’s medical record have clear
documentation of any completed carrier screening. (UW Health Very low quality evidence, strong
recommendation)

Patients should be counseled about the limitations of carrier screening, namely that a negative
test result does not eliminate risk entirely, but reduces risk. (UW Health Very low quality evidence,
weak/conditional recommendation) The partner of an identified carrier should be offered carrier
screening as well. (UW Health Very low quality evidence, weak/conditional recommendation) A
referral to genetic counseling should be considered for women identified as carriers or with
family histories of genetic disease.
Cystic Fibrosis
Cystic Fibrosis is a genetic disorder that causes a buildup of thick, sticky mucus in the lungs,
pancreas and other organs. In the lungs, the mucus clogs the airways and traps bacteria
leading to infections, extensive lung damage, and eventually, respiratory failure. In the
pancreas, the mucus prevents the release of digestive enzymes that allow the body to break
down food and absorb vital nutrients.

As it is increasingly difficult to assign a single ethnicity to individual patients, cystic fibrosis
screening may be offered to all patients.
3,81-83
(UW Health Low quality evidence, weak
recommendation) Screening should be completed using a cystic fibrosis mutation panel and not
gene sequencing. Screening is most efficacious in the non-Hispanic white and Ashkenazi
Jewish populations, and so a residual risk should be provided to all patients. This disease is
also screened for on the newborn screen.
Spinal Muscular Atrophy
Spinal Muscular Atrophy (SMA) is a genetic disorder that results in progressive muscle
weakness and paralysis. The most severe type of SMA is usually diagnosed within the first few
months of life. Affected children have severe muscle weakness and typically do not survive
past the age of 2, if untreated. There are other types of SMA that are less common than the
severe type and involve a lesser degree of muscle weakness. Most affected individual need to
use wheelchairs or need assistance with walking. Life expectancy for the less severe types
ranges from the teenage years to adulthood.

All women who are consider pregnancy or who are pregnant should be offered carrier screening
for spinal muscular atrophy (SMA).
84,85
(UW Health Low quality of evidence, weak/conditional
recommendation) Pretest counseling should include a discussion of the range of severity of the
disease, as well as the limitations of carrier screening in different populations. Screening should
be completed using a SMN1 gene dosage assay (i.e., quantitative polymerase chain reaction)
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Hemoglobinopathies
Hemoglobinopathies are a group of genetic disorders that affect hemoglobin. Some
hemoglobinopathies may cause only mild anemia. Others can cause more significant lifelong
health issues and be life-threatening. Sickle cell anemia is one of the most well-known
hemoglobinopathies.

It is recommended that all pregnant patients be screened for anemia and risk for
hemoglobinopathies via complete blood count with red blood cell indices. Women with a low
mean corpuscular hemoglobin or mean corpuscular volume should be offered hemoglobin
electrophoreses. Pregnant patients of Southeast Asian, African, West Indian, or Mediterranean
descent should be offered hemoglobinopathy screening, as these women are at an increased
risk.
6,35,83,86
(UW Health Moderate quality of evidence, weak/conditional recommendation) Screening
should be offered at the first prenatal visit if it was not offered during pre-conception.

Patients of Southeast Asian, West Indian, or Mediterranean descent
Accurate hemoglobin identification should be completed using a complete blood count (CBC) in
patients of non-African descent.
86
(UW Health Low quality evidence, strong recommendation) If the
results indicate a reduced mean corpuscular volume (MCV < 80 fL) and normal iron studies, a
hemoglobin electrophoresis should be ordered. If the MCV is below normal, iron deficiency
anemia has been excluded, and the hemoglobin electrophoresis is not consistent with β-
thalassemia trait (i.e., there is no elevation of Hb A2 or Hb F), then DNA-based testing should
be used to detect α-globin gene deletions characteristic of α-thalassemia.
86
(UW Health Low
quality evidence, weak/conditional recommendation)

Patients of African descent
For patients of African descent, hemoglobulin testing using a hemoglobin electrophoresis in
addition to a CBC is recommended.
86
(UW Health Low quality evidence, weak/conditional
recommendation) If the MCV is below normal (< 80 fL), iron deficiency anemia has been
excluded, and the hemoglobin electrophoresis is not consistent with β-thalassemia trait (i.e.,
there is no elevation of Hb A2 or Hb F), then DNA-based testing should be used to detect α-
globin gene deletions characteristic of α-thalassemia.
86
(UW Health Low quality evidence,
weak/conditional recommendation)
Fragile X Syndrome
Fragile X Syndrome (FXS) is an X-linked, genetic disorder that causes intellectual disabilities,
behavioral and learning challenges and various physical characteristics. Although it can occur in
both sexes, males are more frequently affected and more severely affected than females.
87

Carrier females can present with ovarian insufficiency before age 40 years. Male or female
carriers of a pre-mutation can present with Fragile-X-associated tremor/ataxia syndrome
(FXTAS).
88


Carrier screening is recommended to women with a family history of fragile X, a family history of
unexpected intellectual disability suggestive of fragile X. (UW Health Low quality evidence,
weak/conditional recommendation) Women with unexplained ovarian insufficiency should be
offered carrier screening too. It is reasonable to offer fragile X screening to a woman that
requests it but does not have an indication after she has been informed of the benefits, limitation
and risks of screening.
83
(UW Health Very Low quality evidence, weak/conditional recommendation)

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19

Tay - Sachs disease
Tay-Sachs disease is a progressive neurodegenerative genetic disorder that often presents in
infancy. There is regression of skills, seizures, loss of vision and hearing, and severe intellectual
disability. Children with the severe form of Tay-Sachs often die within childhood. There are
other forms of Tay-Sachs, although they are less common and often less severe.

Carrier screening is recommended to women if either she or her partner is of Ashkenazi Jewish,
French-Canadian or Cajun descent, ideally prior to pregnancy or at the initial provider visit.
83,89

Anyone with a family history of the disease should be offered carrier screening. (UW Health Low
quality of evidence, strong recommendation) Given these ethnicities, screening can occur with
use of a Tay-Sachs common mutation panel. Although screening can be completed using the
hexosaminidase enzyme level within serum, caution should be exercised as there can false
positive in the pregnant woman or the woman taking oral contraceptive.
Genetic Diseases in Patients of Ashkenazi Jewish Descent
For those couple with at least one person of Ashkenazi Jewish descent, further genetic carrier
screening can be offered. Recommendations for which diseases should be considered vary
amongst professional groups. Referral to a genetic counselor for discussion of carrier screening
options is recommended. (UW Health Very low quality of evidence, weak/conditional
recommendation)
Expanded Carrier Screening
Given advances in technology, a large number of genetic diseases can be screened for
simultaneously regardless of ancestry or family history. Expanded carrier screening can screen
for several to hundreds of disorders, and it is reasonable to consider this option of carrier
screening. Each provider should “establish a standard approach that is consistently offered to
and discussed with each patient, ideally before pregnancy.”
80
(UW Health Very low quality of
evidence, weak/conditional recommendation)



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Immunizations in pregnancy
Influenza vaccination
Pregnant patients infected with the flu have increased rates of hospitalization, cardiopulmonary
complications and death compared with the general population. The Centers for Disease
Control recommends that all pregnant patients receive inactivated influenza vaccination during
the flu season.
90-92
(UW Health Moderate quality of evidence, strong recommendation)
Live attenuated vaccine is contraindicated. It is also recommended that partner, family
members and infant caregivers also be vaccinated during the flu season.
90
(UW Health Moderate
quality of evidence, strong recommendation)
Tetanus, diphtheria and pertussis vaccination (Tdap)
It is recommended to administer Tdap vaccine to all pregnant patients during each pregnancy,
as early as 27-36 weeks gestation.
93,94
(UW Health Moderate quality of evidence, strong
recommendation) Partners, family members and infant caregivers should be offered Tdap as
well, if not previously vaccinated. If vaccination is indicated, it should take place at least 2
weeks before contact with newborn.
90,95
(UW Health Moderate quality of evidence, strong
recommendation)
Labor considerations and planning
Confirm vertex presentation
It is recommended that fetal presentation be assessed and documented beginning at 36 weeks
gestation to allow for external cephalic version.
96
If vertex presentation cannot be confirmed,
limited ultrasound may be considered.
97
(UW Health Low quality of evidence, strong
recommendation)

If the fetus is determined to be in breech presentation, patients should be counseled that if
spontaneous version is to occur, will likely have taken place by 37 0/7 weeks of gestation.
Referral of a patient to Obstetrics for possible external cephalic version or potential scheduled
cesarean section should be considered.
96
(UW Health Low quality of evidence, weak/conditional
recommendation)
Trial of labor after cesarean delivery (TOLAC) discussion
It is recommended to have a thoughtful discussion on labor and delivery plans with patients who
are candidates for vaginal birth after cesarean (VBAC). (UW Health Very low quality of evidence,
strong recommendation) Patients should be informed of the benefits associated with a TOLAC
(e.g., shorter recovery period, lower risk of infection and less blood loss) and also the risks as
well (i.e., rupture of scar on the uterus or rupture of uterus itself.)
98
Any patient wishing to have
a TOLAC should be referred to Obstetrics prior to labor and delivery to ensure informed consent
and labor planning is done in a timely manner. (UW Health Very low quality of evidence, strong
recommendation)
Herpex simplex virus (HSV) suppression
Patients with known recurrent genital herpex simplex virus have a high risk of transmitting HSV
to their neonates. It is recommended to offer acyclovir or valacyclovir at 36 weeks gestation to
decrease risk of clinical lesions and viral shedding at time of delivery, thereby also reducing
need for cesarean section.
99,100
(UW Health High quality of evidence, strong recommendation)
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21

Antepartum Fetal Surveillance

The goal of antepartum fetal surveillance is to prevent fetal death. Antepartum fetal surveillance
techniques include maternal-fetal movement assessment (i.e., “counting kicks”), contraction
stress test, nonstress test, and umbilical artery Doppler velocimetry.
101
Table 9 provides select
indications for antepartum fetal surveillance and suggestions for when to initiate testing and
testing frequency.

Table 9. Common Indications for Antepartum Fetal Surveillance
31,101-105


Diagnosis
Gestational Age
to Initiate Testing
Frequency of
testing
UW Recommendation
Maternal
conditions
Advanced maternal age
(age at delivery ≥ 40
years)
38 weeks Once a week
Moderate evidence,
strong recommendation
Pregnancy
related
conditions
Diabetes, diet
controlled
34 weeks Twice a week
Low quality evidence,
weak/conditional
recommendation
Diabetes, treated with
medication
32 weeks Twice a week
Low quality evidence,
weak/conditional
recommendation
Chronic hypertension* 32 weeks* Twice a week*
Low quality evidence,
weak/conditional
recommendation
Pregnancy-induced
hypertension*
At diagnosis* Twice a week*
Low quality evidence,
weak/conditional
recommendation
Preeclampsia At diagnosis Twice a week
Low quality evidence,
weak/conditional
recommendation
Obesity/BMI ≥ 40 32 weeks Twice a week
Low quality evidence,
weak/conditional
recommendation
Post-term pregnancy
≥ 41 weeks
41 weeks Twice a week
Moderate quality
evidence, strong
recommendation
* For hypertensive disorders related to pregnancy, consider
monitoring with serial growth ultrasounds monthly starting at 28
weeks gestation
Low quality evidence,
weak/conditional
recommendation
Fetus
concerns
Amniotic fluid volume,
oligohydramnios
(AFI < 5 cm)
At diagnosis
Discussed/determined
with maternal fetal
medicine provider
Moderate quality
evidence, strong
recommendation
Growth restricted fetus
28 weeks or at
diagnosis
1-2 times per week or
at discretion of
maternal fetal
medicine provider
Moderate quality
evidence, strong
recommendation
Previous
stillbirth/intrauterine
fetal demise (IUFD)
32 weeks or 2
weeks prior to
previous stillbirth
Twice a week
Moderate quality
evidence, strong
recommendation


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22

Depression in Pregnancy

Depression and anxiety are common in pregnancy and the postpartum period and depression,
in particular, is a common complication of pregnancy and in the post-partum period.
106
The
exact impact of depression on the fetal environment is not known, however postpartum
depression can have a potentially devastating impact on a mother and children. Long term risks
associated with post-partum depression include recurrence of peripartum and non-peripartum
depression and children of mothers with peripartum depression are at increased risk for
development delays and behavioral problems.
107,108
Given depression in pregnancy is a risk
factor for peripartum depression, screening for and treating depression in pregnancy is critical.

Risk Factors for Depression
Risk factors are often intertwined and related, and may vary based upon patient age and
experiences. Patients with chronic illnesses such as diabetes, cardiovascular disease, and
chronic pain are at a higher risk for depression.
109,110
Table 10 lists risk factors for depression in
pregnancy.

Table 10. Risk Factors for depression in pregnancy*
108

Biological
• Personal history of depression
• Unintended pregnancy
• Concurrent anxiety
Environmental
• Low socioeconomic status
• Exposed to domestic violence
• Single

• Lack of social support
• Stressful life events
*Risk factors for postpartum depression are similar to those for depression in pregnancy. In addition, women with
depression during pregnancy have an elevated risk of postpartum depression.
108


Screening for depression in pregnancy (12 years or older)
Pregnant adolescents or adults should be screened at the first prenatal visit, during the third
trimester (24-32 weeks), and at six weeks postpartum.
109,111-113
(UW Health Low quality evidence,
strong recommendation) Screening may be completed using the Edinburgh Postnatal Depression
Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9) or Patient Health Questionnaire-A
(PHQ-A) assessment tools.
111,114


A total score of 10 points of greater on the EPDS constitutes the need for clinical evaluation and
documentation of a follow-up plan. An affirmative response to Question 10 (suicidality)
constitutes the need to access crisis intervention services.
115


Edinburgh Postnatal Depression Scale (EPDS)
Population Postpartum patients
Number of Questions 10
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (At-Risk)
Positive Threshold (Suicide Risk)

30 points
10 points or greater
Affirmative response to Question 10
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23

A total score of 10 points or greater on the PHQ-9 or PHQ-A indicates the need for clinical
evaluation and documentation of a follow-up plan.
116,117

Follow-up Plan Documentation
According to the ACO Quality measure, all patients who screen positive on a validated
depression screening tool must have a documented follow-up plan on the date of the positive
screen. This plan must contain one or more of the following:
• Additional evaluation for depression
• Suicide Risk Assessment
• Referral to a practitioner who is qualified to diagnose and treat depression
• Pharmacological interventions
• Other interventions or follow-up for the diagnosis or treatment of depression.

For additional information on postpartum depression, refer to the UW Health Depression:
Diagnosis and Treatment – Adult/Pediatric/ Ambulatory clinical practice guideline.
Treatment of depression in pregnant patient (12 years or older)
The treatment of depression during pregnancy should be completed using a shared-decision
making process which weighs the potential risk of fetal exposure to psychotropic medication
against the potential adverse effects of an untreated disorder.
109,113,118
(UW Health Low quality
evidence, weak recommendation) It is important to engage the patient and significant others in this
discussion about what is best for their situation (patient’s preference), what treatment options
are available, and that the ultimate goal is for the patient and baby to be as safe as possible.
119

The treatment decision may also depend on the patient's history of depression prior to
pregnancy, past experience with medications, severity of the depression, support available,
response to alternative treatment modalities, etc.

Psychotherapy (IPT or CBT) is recommended whenever possible for mild to moderate
depression, in patients who have exhibited a positive response in the past, or by patient
preference.
118,120
(APA Grade I) Interpersonal therapy is considered to be particularly useful
during pregnancy as it directly addresses issues associated with role transitions and
relationships with the partner.

Patients, who have become significantly depressed while off antidepressant medication in the
past, will likely need to continue taking antidepressant medication in pregnancy to prevent
recurrence of symptoms. Pregnant patients with new onset of moderate to severe depression in
pregnancy may require medication in addition to psychotherapy to ensure the best treatment
response.
109,120
(APA Grade II) The goal of pharmacotherapy is to treat to remission to avoid
exposing the infant to both the antidepressant medication and maternal depression. Refer to
Appendix B for screening and initial treatment algorithm for depression in pregnancy.

Current evidence is insufficient to establish a direct relationship between antidepressant use
during pregnancy and risks or adverse birth outcomes.
118,121
Select serotonin reuptake inhibitors
(SSRIs), except for paroxetine and tricyclic antidepressants (TCAs) may be used if preferred by
the patient. (UW Health Low quality evidence, weak/conditional recommendation) Paroxetine (FDA
category D) is not recommended in women who are planning to become pregnant or for use in
early pregnancy (i.e., first trimester) as some studies have found increased risk of cardiac
defects with more than 25 mg/day of paroxetine use in the first trimester.
118,122,123
(UW Health Low
quality evidence, weak/conditional recommendation) Table 11 lists select medications that are
considered preferred for treatment of depression in pregnancy. For additional information on
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24

medication dosing and side effects, refer to Appendix C or the UW Health Depression:
Diagnosis and Management clinical practice guideline.


Table 11. Select medications for pharmacologic treatment of depression in pregnancy
Pregnancy Lactation
Preferred
• Sertraline
• Citalopram
• Escitalopram
• Sertraline
• Paroxetine
May
Consider
• Fluoxetine
• Bupropion (if smoking cessation concurrent issue)
• Paroxetine (in late pregnancy/post-partum)
• Tricyclic antidepressants
• Fluvoxamine
• Citalopram
• Venlafaxine
• Escitalopram
Limited data
• Venlafaxine
• Fluvoxamine
• Mirtazapine
• Mirtazapine
• Bupropion

Discouraged
• Paroxetine (in 1
st
trimester) • Fluoxetine
Electroconvulsive therapy (ECT) is an additional treatment option for patients who are pregnant
with depression and psychotic or catatonic feature, moderate to severe depression
unresponsive to pharmacotherapy or psychotherapy, or by patient preference.
120
(APA Grade II)
Any patient who is considering ECT for depression treatment should be referred to and
evaluated by Psychiatry prior to ECT initiation. (UW Health Very low quality evidence, strong
recommendation)
Patient education on depression
It is important to educate patients on depression and the important of adhering to treatment.
Patients may not realize that the full effect of medication may not occur for a few weeks despite
some immediate side effects of antidepressant medication thus it is important to have a frank
discussion with the patient surrounding depression and its treatment. Table 12 offers some
counseling points to discuss with when initiating pharmacotherapy.

Table 12. Suggested counseling points when initiating pharmacotherapy for depression
• Antidepressants must be taken daily for 2-4 weeks for a noticeable effect.
• Educate patient on potential side effects which may occur before full effect of medication is
noticed. Many side effects typically resolve after 1-2 weeks and usually by the time
medication is in full effect.
• Take medication daily as prescribed. Do not stop taking antidepressant without checking
with your provider. Some antidepressants may have uncomfortable withdrawal symptoms.
• Continue to take medication even if you are feeling better due to an increased risk of relapse
if stopped before 6 months.
• Contact your provider and/ or pharmacy if you have questions about your medication(s).
• Be sure to make and keep follow-up appointments. This is important to ensure full response
to your medication.
• The medication is not addictive and will not change your personality. Depression alters brain
functioning and the medication helps restore normal patterns, so you eat and sleep more
normally, think more clearly and have more energy.
• The medication should help you benefit from the psychotherapy you are receiving.
• Do not drink alcohol during pregnancy and especially while taking medication.
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25


Methodology
Development Process
Each guideline is reviewed and updated a minimum of every 3 years. All guidelines are
developed using the guiding principles, standard processes, and styling outlined in the UW
Health Clinical Practice Guideline Resource Guide. This includes expectations for workgroup
composition and recruitment strategies, disclosure and management of conflict of interest for
participating workgroup members, literature review techniques, evidence grading resources,
required approval bodies, and suggestions for communication and implementation.

Methods Used to Collect the Evidence:
The following is a list of various search terms that were used individually or in combination with
each other for literature searches on PubMed: depression, pregnancy, antidepressant side
effect, lactation, prenatal guideline, antepartum fetal surveillance, hepatitis c screening, prenatal
screening, vaccination pregnant, maternal mental heatlh, acog practice bulletin, acog committee
opinion, fetal health surveillance, obesity, antenatal testing, hypothyroidism.

Literature Sources:
• Electronic database search (e.g., PubMed)
• Databases of systematic reviews (e.g., Cochrane Library)
• Hand-searching journals, external guidelines, and conference publications
• Medical textbooks/references

Time Period: October 2017 to December 2017

Methods to Select the Evidence:
Literary sources were selected with the following criteria in thought: English language, subject
age (i.e., age ≥12 years), publication in a MEDLINE core clinical journal and strength of expert
opinion (e.g., professional society guideline).

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or created recommendations internally via a consensus process using
discussion of the literature and expert experience/opinion. If issues or controversies arose
where consensus could not be reached, the topic was escalated appropriately per the guiding
principles outlined in the UW Health Clinical Practice Guideline Resource Guide.

Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1).
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26

Figure 1. GRADE Methodology adapted by UW Health

Rating Scheme for the Strength of the Evidence/Recommendations:

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and preferences, the
resources available, or the setting in which the intervention will be implemented.


U.S Preventive Services Task Force (USPSTF) Grades for Recommendations
A
The USPSTF recommends the service. There is high certainty that the net benefit is
substantial
B
The USPSTF recommends the service. There is high certainty that the net benefit is
moderate or there is moderate certainty that the net benefit is moderate to substantial.
C
The USPSTF recommends selectively offering or providing this service to individual
patients based on professional judgment and patient preferences. There is at least
moderate certainty that the net benefit is small.
D
The USPSTF recommends against the service. There is moderate or high certainty that
the service has no net benefit or that the harms outweigh the benefits.
I Statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and
the balance of benefits and harms cannot be determined.





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27

Infectious Diseases Soceity of America-US Public Health Grading System for Ranking
Recommendations in Clinical Guidelines
Category, grade Definition
A Good evidence to support a recommendation for use; should always be offered
B Moderate evidence to support a recommendation for use; should generally be
offered
C Poor evidence to support a recommendation; optional
D Moderate evidence to support a recommendation against use; should generally
not be offered
E Good evidence to support a recommendation against use; should never be
offered
Quality of Evidence
I Evidence from ≥ 1 properly randomized, controlled trial
II Evidence from ≥ 1 well-designed clinical trial, without randomization; from cohort
or case-controlled analytic studied (preferably from >1 center); from multiple time-
series; or from dramatic results from uncontrolled experiments properly
randomized, controlled trial
III Evidence from opinions of respected authorities, based on clinical experience,
descriptive studies, or reports or expert committees

Centers for Disease Control and Prevention Evidence Based Rating System
Category Definition Recommendation
A Strong evidence for efficacy and substantial clinical benefit Strongly recommended
B Strong or moderate evidence for efficacy but only limited clinical benefit Generally recommended
C Insufficient evidence for efficacy or efficacy does not outweigh possible
adverse consequences
Optional
D Moderate evidence against efficacy or for adverse outcome Generally not
recommended
E
Strong evidence against efficacy or for adverse outcome Never recommended
Quality of Evidence
I
Evidence from at least one well-executed randomized, controlled trial or one rigorously designed
laboratory-based experimental study that has been replicated by an independent investigator
II
Evidence from at least one well-designed clinical trial without randomization, cohort or case-controlled
analytic studies (preferably from more than one center), multiple time-series studies, dramatic results
from uncontrolled studies, or some evidence from laboratory experiments
III
Evidence from opinions of respected authorities based on clinical or laboratory experience, descriptive
studies, or reports of expert committees

American Thyroid Association (ATA) Recommendations Based on Strength of Evidence
Recommendation
strength
Quality of
evidence
Description of supporting
evidence
Interpretation
Strong
recommendation
High
RCT without important limitations
or overwhelming evidence from
observational studies
Can apply to most patients in most
circumstances without reservation
Moderate
RCT with important limitations or strong
evidence from observational studies
Can apply to most patients in most
circumstances without reservation
Low
Observational studies/case studies May change when higher-quality
evidence becomes available
Weak
recommendation
High
RCT without important limitations
or overwhelming evidence from
observational studies
Best action may differ based on
circumstances or patients’ values
Moderate
RCT with important limitations or strong
evidence from observational studies
Best action may differ based on
circumstances or patients’ values
Low
Observational studies/case studies Other alternative may be equally
reasonable
Insufficient
Evidence is conflicting, or poor quality
or lacking
Insufficient evidence to recommend
for or against
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28

Recognition of Potential Health Care Disparities: The American College of Obstetricians and
Gynecologists (ACOG) recognizes that there may be racial and ethnic disparities in obstetric
and gynecologic outcomes between various ethnic groups (e.g., Blacks, Whites, Asians,
Hsipanics, Native American, Alaksa Natives.) While examples are prevalent in the literature
outlinging differences in outcomes between black and white women, more information is needed
to explore disparities among Amerian Indian, Alaska Native and Asian women.
124

Collateral Tools & Resources
The following collateral tools and resources support staff execution and performance of the
evidence-based guideline recommendations in everyday clinical practice.

Metrics
• Number of patients who had urinalysis and urine culture obtained at initial prenatal visit
• Number of pregnant patients with hypothyroidism with thyroid level check at 20 weeks and at 30
weeks gestation
• Number of patients who had 50 gram OGTT with level < 140 mg/dL who had 100 gram OGTT
ordered
• Number of patients who screened positive for GBS prior to third trimester of current pregnancy
who had vaginal swab obtained


Related Guidelines
Depression: Diagnosis and Management – Adult/Pediatric – Ambulatory
Prevention and Management of Obesity – Adult – Ambulatory
Prevention and Management of Obesity – Pediatric – Ambulatory
Preventive Health Care – Adult/Pediatric – Ambulatory

Order Sets & Smart Sets
OB Initial Visit [306]
OB Initial Visit Eau Claire/Augusta [262]
OB Initial Visit – UWHC [2545]
OB PreGravid BMI BPA [4524]
OB Prenatal Intake ACHC [164]
OB Visit [120]
OB Visit Eau Claire/Augusta [292]
OB Visit – UWHC [2548]
Pre-Eclampsia Labs [394]
Bariatric OB Prenatal Care [6544

Patient Resources
HFFY 5457 – Coping with Nausea and Vomiting in Pregnancy
HFFY 5456 – Help for Common Symptoms while Pregnant
HFFY 6687 – Having a VBAC (Vaginal Birth after Cesarean Section)
HFFY 5715 – Group B Streptococcal Infections
HFFY 5811 – Pregnancy, Coping with Nausea and Vomiting (Spanish)
HFFY 5805 – Common Symptoms in Pregnancy (Spanish)
HFFY 7979 – Getting Ready for your Fasting Blood Draw

Clinical Policies
UWHC Policy 3.5.1 – Screening of Possibly Pregnant, or Pregnant Patients Prior to Diagnostic
Radiological Exam
UWHC 4.30- Consent for HIV Testing and Release of Protected Health Information

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29


Delegation Protocols
New OB Patient Laboratory and Diagnostic Test Ordering – Adult – Ambulatory [116]
Gestational Diabetes Screening and Treatment – Adult/Pediatric- Ambulatory [22]
Treatment of Nausea in Pregnancy – Adult/Pediatric – Ambulatory [157]
First Trimester Bleeding – Adult/Pediatric – Ambulatory [112]
Treatment of Anemia During Pregnancy – Adult/Pediatric – Ambulatory [68]
Urine Pregnancy Test Ordering – Adult/Pediatric – Ambulatory [113]

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30

Appendix A. Overview of Prenatal Care


History and Examination Tests and Immunizations Counseling/Discussion
topics
G
e
s
t
a
t
i
o
n
a
l

A
g
e

Entry of
prenatal
care –
12
weeks
• Document last menstrual cycle; if
pregnancy dating unknown, offer
dating ultrasound to ideally occur
~7-8 weeks gestation
• Document pre-gravid weight
• Obtain relevant medical history
related to current pregnancy
(e.g., hx of preterm deliveries,
chronic medical conditions)
• Obtain current medication profile
including whether or not taking
prenatal vitamin/folic acid
• Screen for depression
• Complete physical exam
including height, weight, blood
pressure and pelvic examination
• Check fetal heart rate
• Complete blood count with differential
• Urine pregnancy and screening urine culture
• Rubella antibody, IgG
• Antibody testing (i.e., ABO and Rh typing,
antibody screen)
• HIV AB/AG combo
• Chlamydia/gonorrhea screen
• Syphilis screen
• Hepatitis B screen
• Pap smear (if indicated)
• Hepatitis C screen (if indicated)

• Pregnancy dating ultrasound (if indicated)

Tests/interventions for special populations (as
indicated)
• A1c measurement
• Creatinine
• Uric acid
• AST/ALT
• Protein/creatinine ratio
• TSH, free T4

Prenatal screening tests
• Maternal cell free DNA screen/ non invasive
prenatal testing (NIPT)
• First trimester screen

Immunizations
• Influenza vaccination
• Weight gain in
pregnancy

• Lifestyle
considerations in
pregnancy

• Introduce/offer
prenatal screening
options for aneuploidy
and carrier screening

• Review pregnancy
dating results (if
applicable)

• Follow-up
documentation/treatm
ent options discussion
if screen positive for
depression
12-16
weeks
• Physical exam including height,
weight, blood pressure
• Check fetal heart rate

Tests/interventions for special populations (test
if indicated)
• TSH(every 4 weeks)
• Weekly progesterone administration (if history
of spontaneous preterm delivery; initiate at 16
weeks)

Prenatal screening tests
• AFP (recommended if NIPT/First trimester
screen)
• Quad screen

Immunizations
• Influenza vaccination
• Review
test/ultrasound results

• Offer/discuss prenatal
screening options with
patient (e.g., AFP if
had NIPT or First
Trimester Screen)


16-22
weeks
• Physical exam including height,
weight, blood pressure and
fundal height
• Check fetal heart rate
• 20 week ultrasound (fetal anatomy)

Tests/interventions for special populations (test
if indicated)
• TSH (every 4 weeks)
• Weekly progesterone administration (if history
of spontaneous preterm delivery)

Prenatal screening tests
• AFP
• Quad screen

Immunizations
Influenza vaccination
• Review
test/ultrasound results

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31





History and Examination Tests and Immunizations Counseling/Discussion
topics
G
e
s
t
a
t
i
o
n
a
l

A
g
e

22-28
weeks
• Complete physical exam
including height, weight, blood
pressure and fundal height
• Check fetal heart rate
• 50 gram oral glucose tolerance test (24-28
weeks)
• Fasting oral glucose test (as indicated)


Tests/interventions for special populations (test
if indicated)
• TSH (may stop regular assessment if patient
is stable)
• Weekly progesterone administration (if
history of spontaneous preterm delivery)


Immunizations
• Influenza vaccination
• Review
test/ultrasound results

• Discuss TOLAC with
patient (if candidate)
and refer patient to
Obstetrics to ensure
informed consent
obtained in timely
manner
28-34
weeks
• Physical exam including height,
weight, blood pressure, fundal
height
• Check fetal heart rate
• Screen for depression
• Antepartum fetal surveillance (if indicated)

Tests/interventions for special populations (test
if indicated)
• TSH (check at least once ~30 weeks))
• Weekly progesterone administration (if
history of spontaneous preterm delivery)


Immunizations
• Influenza vaccination
• Tdap vaccination (27-36 weeks)
• Discuss TOLAC with
patient (if candidate)
and refer patient to
Obstetrics to ensure
informed consent
obtained in timely
manner

34-38
weeks
• Physical exam including height,
weight, blood pressure, fundal
height
• Check fetal heart rate
• Screen for depression
• Group B strep culture (35-37 weeks)

• Limited ultrasound (~37 weeks, as needed
for vertex presentation confirmation)

• Antepartum fetal surveillance (if indicated)

Tests/interventions for special populations (test
if indicated)
• HIV AB/AG combo (if indicated)
• Chlamydia/gonorrhea screen (if indicated)
• Syphilis screen (if indicated; required in IL)

Immunizations
• Influenza vaccination
• Tdap vaccination (27-36 weeks)
• Offer suppressive
anti-viral therapy to
patients with recurrent
genital HSV at 36
weeks or beyond
38
weeks-
delivery
• Physical exam including height,
weight, blood pressure, fundal
height
• Check fetal heart rate
• Screen for depression
• Antepartum fetal surveillance (if indicated) • Discuss potential for
labor induction with
patient, as necessary



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32

Appendix B. Depression in pregnancy algorithm
108,125,126


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33

Appendix C. Pharmacotherapy options for Perinatal Depression
106,125,127-132

Medication
Pregnancy
Category*
Lactation
Risk
Category
Dosage Pregnancy/Lactation considerations Side Effects to Consider
Citalopram
(Celexa)
C L3
Start 20 mg daily, may increase to 40 mg daily
after 1 week


Max 40mg/day
Use in pregnancy: Preferred in pregnancy;
When taken at term, 10-30% babies may
experience self-limited poor neonatal
adaptation syndrome.

Higher risk for sexual dysfunction,
QT interval prolongation
Escitalopram
(Lexapro)
C
L3 in older
infants
Start 10 mg daily; may increase dose after 1
week

Max 20mg/day
Use in pregnancy: Limited data Lowest risk GI side effect and liver
toxicity; may help anxiety
Fluoxetine
(Prozac)
C
L2 in older
infants,
L3 if used
in neonatal
period
Start 20 mg daily (in morning); increase dose
after several weeks


Max 80 mg/day
Use in pregnancy: Preferred drug

Breastfeeding: Decreased weight gain
reported but unclear if from drug or
depression; Use not recommended during
lactation unless it is effective treatment for
mother
May worsen anxiety and agitation;
lowest risk for sexual dysfunction
Long half life; approved for OCD,
bulimia and panic disorder
Fluvoxamine
(Luvox)
C L2
Start 50 mg daily (in the evening); may
increase by 50 mg/day every 4-7 days

Max 300 mg/day
Use in pregnancy: Poor neonatal adaptation
syndrome (irritability, poor feeding,
respiratory distress) may occur; limited data
on use, not recommended

Breastfeeding: May be considered
Highest rate GI side effects,
lowest risk sexual dysfunction
Paroxetine
(Paxil)
D L2
Start 20 mg twice a day; may increase by 1-
mg/day every week

Max 50 mg/day
Use in pregnancy: Studies have
demonstrated increased risk for cardiac
malformations when taken during pregnancy
(1
st
trimester exposure); not recommended in
pregnancy or patients trying to conceive

Consider fetal echocardiography if paroxetine
exposure in early pregnancy

Breastfeeding: Preferred for lactation as
levels are very low in breastmilk
Weight gain more likely compared
to other SSRIs; can be sedating
and high risk for sexual
dysfunction; approved for OCD,
panic disorder, anxiety, and PTSD
Sertraline
(Zoloft)
C L2
Start 25 mg daily for first 3-5 days then 50 mg
daily; increase by 25-50 mg/daily every 1-2
weeks

Max 200 mg/day
Use in pregnancy:
Preferred in pregnancy
Neonatal poor adaptation syndrome may
occur.

Breastfeeding: Preferred for lactation as
levels are very low in breastmilk
May help anxiety and sleep
quality; more diarrhea relative to
other SSRIs
Trazodone
(Oleptro)
C L2
Start at 150 mg/day in divided doses; increase
in 50 mg/day increments every 3-4 days

Max 600 mg/day
Breastfeeding: Excreted in breast milk,
though in very small quantities
Somnolence; dose at night and
use in patients with concurrent
insomnia
*Prior to 2016, U.S Food and Drug Administration classified drug safety with following categories: A, controlled studies show no risk; B, no evidence of risk in humans; C, risk cannot
be ruled out; D, positive evidence of risk; X, contraindicated in pregnancy.
£ Lactation risk categories are listed as follows: L1, safest; L2, safer; L3, moderately safe; L4, possibly hazardous; L5, contraindicated.
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34


Medication
Pregnancy
Category*
Lactation
Risk
Category
£

Dosage Pregnancy/Lactation
considerations
Side Effects to Consider
Amitriptyline
(Elavil)
C L2
Start at 25-50 mg/day in a single dose at bedtime
or in divided doses; gradually increase if
inadequate response

Max 300 mg/day
TCAs considered safe in pregnancy
however side effect profile may not be
desirable to pregnant patients

Anticholinergic side effects (i.e.,
dry mouth, constipation, blurred
vision, drowsiness, orthostatic
hypotension)
Desipramine C L2
Start at 25-50 mg once daily or in divided doses.
Gradually increase if inadequate response

Max 300 mg/day

Nortriptyline
(Pamelor)
C L2
Start at 75-100 mg once daily or in divided doses.
Gradually increase if inadequate response.

Max 150 mg/day
Breastfeeding: Preferred for lactation

Doxepin C L5
Start at 25-50 mg once daily or in divided doses.
Gradually increase if inadequate response

Max 300 mg/day
Breastfeeding: Associated with sedation
and respiratory depression in case reports
of exposed infants; avoid in breastfeeding

Desvenlafaxine
(Pristiq)
C L3
Start at 50 mg/day. Increase as tolerated.

Max 400 mg/day
Breastfeeding: Limited data, not first line
for lactation

Duloxetine
(Cymbalta)
C N/A
Start at 40 to 60 mg daily; dose may be divided
(i.e., 20 or 30 mg BID) or given as a single daily
dose of 60 mg. Alternatively may start at 30
mg/day and increase to 60 mg/day after at least
one week

Max 60 mg/day

Venlafaxine
(Effexor)
C L3
Start at 37.5-75 mg/day in 2 or 3 divided doses;
increase by 75 mg/day increments every 4 days

Max 375 mg/day
Use in pregnancy: Limited data on use

Breastfeeding: May be considered but not
first line
Nausea and vomiting common side
effect; if used, recommend with
food
Bupropion
(Wellbutrin)
C L3
IR tablet - Start at 100 mg twice daily; after 3 days
may increase to 100 mg three times daily. After
several weeks may increase to 150 mg three times
daily

Max 450 mg/day
Use in pregnancy/breastfeeding:
Bupropion should be avoided in patients
due to reduced seizure threshold; avoid in
infants with history of seizure, including
febrile seizures and parent/sibling history
of seizure; may help patients also
suffering from nicotine addiction

Considered stimulant
antidepressant; take in morning
and may exacerbate insomnia
Mirtazapine
(Remeron)
C L3
Start at 15 mg/day; may increase by 15 mg/day
increments every 1-2 weeks.

Max 45 mg/day
Use in pregnancy:
Limited data on use

Weight gain, increased appetite
common side effects
Somnolence; dose at night and
use in patients with concurrent
insomnia
*Prior to 2016, U.S Food and Drug Administration classified drug safety with following categories: A, controlled studies show no risk; B, no evidence of risk in humans; C, risk cannot
be ruled out; D, positive evidence of risk; X, contraindicated in pregnancy.
£ Lactation risk categories are listed as follows: L1, safest; L2, safer; L3, moderately safe; L4, possibly hazardous; L5, contraindicated.
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35

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