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VA Dod Clinical Practice Guideline for the Management of Pregnancy

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VA Dod Clinical Practice Guideline for the Management of Pregnancy VA/DOD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF PREGNANCY Department of Veterans Affairs Department of Defense QUALIFYING STATEMENTS The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best information available at the time of publication. They are designed to provide information and assist decision making. They are not intended to define a standard of care and should not be construed as one. Neither should they be interpreted as prescribing an exclusive course of management. This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical relationships between various care options and health outcomes while rating both the quality of the evidence and the strength of the recommendation. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of applying them in the setting of any particular clinical situation. These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy. Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed Care Support Contractor. Version 3.0 – 2018 VA/DoD Clinical Practice Guideline for the Management of Pregnancy Prepared by: The Management of Pregnancy Work Group With support from: The Office of Quality, Safety and Value, VA, Washington, DC & Office of Evidence Based Practice, U.S. Army Medical Command Version 3.0 – 2018 Based on evidence reviewed through May 2017 March 2018 Page 2 of 147 VA/DoD Clinical Practice Guideline for the Management of Pregnancy Table of Contents I. Introduction ..................................................................................................................................... 6 II. Background...................................................................................................................................... 6 A. Description of Pregnancy .................................................................................................................... 6 B. Epidemiology and Impact in the General Population ........................................................................ 7 a. Rates of Reproduction ................................................................................................................. 7 b. Pregnancy Complications ............................................................................................................ 7 C. Pregnancy in the Department of Defense and the Department of Veterans Affairs Populations ... 8 a. Location of Care ........................................................................................................................... 8 b. Rates of Reproduction ................................................................................................................. 9 c. Complications .............................................................................................................................. 9 III. About this Clinical Practice Guideline ............................................................................................. 10 A. Methods ............................................................................................................................................. 10 a. Grading Recommendations ....................................................................................................... 11 b. Reconciling 2009 Clinical Practice Guideline Recommendations ............................................. 13 c. Peer Review Process .................................................................................................................. 14 B. Summary of Patient Focus Group Methods and Findings ................................................................ 14 C. Conflicts of Interest ........................................................................................................................... 15 D. Scope of this Clinical Practice Guideline ........................................................................................... 16 E. Highlighted Features of this Clinical Practice Guideline ................................................................... 16 F. Patient-centered Care ....................................................................................................................... 16 G. Shared Decision Making .................................................................................................................... 17 H. Co-occurring Conditions .................................................................................................................... 17 I. Implementation ................................................................................................................................. 18 IV. Guideline Work Group ................................................................................................................... 19 V. Algorithm ...................................................................................................................................... 20 A. Algorithm Key .................................................................................................................................... 21 B. Actions at Every Visit ......................................................................................................................... 21 C. Interventions by Weeks Gestation .................................................................................................... 21 D. Standard of Pregnancy Care .............................................................................................................. 23 a. Additional Information on Actions at Every Visit ...................................................................... 23 b. Screenings .................................................................................................................................. 24 c. Time Sensitive Care .................................................................................................................... 28 d. Summary .................................................................................................................................... 28 March 2018 Page 3 of 147 VA/DoD Clinical Practice Guideline for the Management of Pregnancy VI. Routine Pregnancy Care ................................................................................................................. 29 VII. Recommendations ......................................................................................................................... 33 A. Care Throughout Pregnancy .............................................................................................................. 36 a. Routine Care During Pregnancy ................................................................................................ 36 b. Nutrition ..................................................................................................................................... 39 c. Screening .................................................................................................................................... 40 d. Education ................................................................................................................................... 43 B. One-time Interventions ..................................................................................................................... 44 a. Screening and Diagnostic Testing ............................................................................................. 44 b. Imaging ...................................................................................................................................... 49 c. Preparing for Delivery ................................................................................................................ 50 d. Postpartum Care ........................................................................................................................ 51 C. Referral ............................................................................................................................................... 52 D. Special Considerations ....................................................................................................................... 55 a. High Risk for Preeclampsia ........................................................................................................ 55 b. High Risk for Preterm Delivery .................................................................................................. 56 c. Over 44 Years of Age ................................................................................................................. 57 d. History of Bariatric Surgery ....................................................................................................... 58 Appendix A: Evidence Review Methodology ......................................................................................
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