March 2018 Page 1 of 40

VA/DOD CLINICAL PRACTICE GUIDELINE FOR 

THE MANAGEMENT OF PREGNANCY

Department of Veterans Affairs

Department of Defense

Clinician Summary

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 – Clinician Summary

March 2018 Page 2 of 40

Table of Contents 

I. Introduction..................................................................................................................................... 3

II. Recommendations........................................................................................................................... 4

III. Algorithm ........................................................................................................................................ 7

A. Algorithm Key ...................................................................................................................................... 8

B. Actions at Every Visit ........................................................................................................................... 8

C. Interventions by Weeks Gestation...................................................................................................... 8

D. Standard of Pregnancy Care..............................................................................................................10

IV. Routine Pregnancy Care................................................................................................................. 16

V. Scope of the CPG............................................................................................................................ 20

VI. Methods........................................................................................................................................ 20

VII. Guideline Work Group ................................................................................................................... 23

VIII. Patient-centered Care.................................................................................................................... 24

IX. Shared Decision Making................................................................................................................. 24

X. Discussion of Recommendations.................................................................................................... 24

A. Care Throughout Pregnancy..............................................................................................................24

B. One-time Interventions.....................................................................................................................28

C. Referral...............................................................................................................................................30

D. Subpopulations..................................................................................................................................31

References ............................................................................................................................................ 34
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I. Introduction

The Department of Veterans Affairs (VA) and the Department of Defense (DoD) Evidence-Based Practice 

Work Group (EBPWG) was established and first chartered in 2004, with a mission to advise the “...Health 

Executive Council on the use of clinical and epidemiological evidence to improve the health of the 

population across the Veterans Health Administration and Military Health System,” by facilitating the 

development of clinical practice guidelines (CPGs) for the VA and DoD populations.[ ] This CPG is intended 

to provide healthcare providers with a framework by which to evaluate, treat, and manage the individual 

needs and preferences of pregnant women, thereby leading to improved clinical outcomes.

1

In 2009, the VA and DoD published a CPG for the Management of Pregnancy (2009 Pregnancy CPG), which 

was based on evidence reviewed through December 2007. Since the release of that guideline, a growing 

body of research has expanded the general knowledge and understanding of pregnancy and its 

management. Consequently, a recommendation to update the 2009 Pregnancy CPG was initiated in 2016. 

The updated CPG includes objective, evidence-based information on the management of pregnancy. It is 

intended to assist healthcare providers in all aspects of care for a pregnant woman. The system-wide goal 

of developing evidence-based guidelines is to improve patients' health and well-being by guiding health 

care providers who are taking care of pregnant women along the management pathways that are 

supported by evidence. The expected outcome of successful implementation of this guideline is to:

• Assess the condition of the mother and baby and determine the best management method in

collaboration with the mother and, when possible and desired, other family and caregivers

• Optimize the mother and baby’s health outcomes and improve quality of life

• Minimize preventable complications and morbidity

• Emphasize the use of patient-centered care (PCC)
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II. Recommendations

The following recommendations were made using a systematic approach considering four domains as per 

the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach as detailed 

in the section on and Appendix A in the full text Pregnancy CPG. These domains include: 

confidence in the quality of the evidence, balance of desirable and undesirable outcomes (i.e., benefits and 

harms), patient or provider values and preferences, and other implications, as appropriate (e.g., resource 

use, equity, acceptability). 

Methods

# Recommendation Strength* Category†

Care Throughout Pregnancy

a. Routine Care During

Pregnancy

1. We suggest offering a group model of prenatal care as an 

acceptable alternative to individual provider appointments. Weak for Not reviewed, 

Amended

2.

We recommend that all healthy, pregnant women without 

known contraindications participate in regular mild to moderate 

exercise sessions, three or more times per week.

Strong for Reviewed, 

Amended

3. We suggest that women with uncomplicated pregnancies 

continue a standard work schedule throughout their pregnancy. Weak for Not reviewed, 

Amended

b. Nutrition

4.

We recommend folic acid (at least 400 micrograms daily) to be 

taken starting one month before conception and continued 

throughout pregnancy and breastfeeding.

Strong for Not reviewed, 

Amended

c. Screening

5.

We recommend screening for use of tobacco, alcohol, illicit 

drugs, and unauthorized use of prescription medication because 

their use is common and can result in adverse outcomes. For 

women who screen positive, we recommend additional 

evaluation and treatment (see VA/DoD Clinical Practice 

Guidelines for the Management of Substance Use Disorders1

and the Management of Tobacco Use2

). 

Strong for Reviewed, 

Amended

6.

We recommend screening for depression using a standardized 

tool such as the Edinburgh Postnatal Depression Scale or the 9-

item Patient Health Questionnaire periodically during pregnancy 

and postpartum. 

Strong for Reviewed, 

New-replaced

d. Education

7.

We recommend breastfeeding education, assessment, and 

support to all pregnant women and their families at the first visit 

and throughout the pregnancy and postpartum period using 

open-ended questions such as “What do you know about 

breastfeeding?” 

Strong for Reviewed, 

New-replaced

1 See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Available at: 

https://www.healthquality.va.gov/guidelines/mh/sud/ 2 See the Clinical Practice Guideline for the Management of Tobacco Use. Available at: 

https://www.healthquality.va.gov/CPGArchives.asp
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# Recommendation Strength* Category†

One-time Interventions

a.

Screening and Diagnostic Testing

8. We suggest making prenatal diagnostic testing for aneuploidy 

available to all pregnant women. Weak for Reviewed, 

New-replaced

9.

We recommend offering prenatal screening for aneuploidy and 

the most common clinically significant genetic disorders to all 

pregnant women. When aneuploidy screening is desired, cellfree fetal DNA screening should be considered; however, 

screening test selection should be individualized and take into 

account the patient’s age, baseline aneuploidy risk, and test 

performance for a given condition.

Strong for Reviewed, 

New-replaced

10.

We suggest the two-step process (one-hour oral glucose 

challenge test followed by three-hour oral glucose tolerance 

test) to screen for gestational diabetes mellitus at 24-28 weeks 

gestation for all pregnant women.

Weak for Reviewed, 

New-replaced

One-time Interventions (cont.)

b. Imaging

11.

We recommend first-trimester ultrasound to establish or 

confirm the gestational age and estimated birth date, identify 

multiple pregnancies, and confirm the presence of cardiac 

activity.

 For pregnant women who present after the first trimester, 

we suggest performing a dating and anatomical ultrasound 

at the earliest opportunity, preferably prior to 22 weeks. 

Strong for Reviewed, 

New-replaced

c. Preparing

for Delivery

12.

We recommend offering scheduled delivery to women who 

reach 41 weeks and 0/7 days undelivered. Antepartum fetal 

testing should begin at 41 weeks and 0/7 days if not scheduled 

for delivery.

Strong for Reviewed, 

Amended

d.

Postpartum

Care

13.

For pregnant women who have a past or current history of 

gestational diabetes mellitus, hypertension, or preeclampsia, we 

recommend documenting the reproductive history and making 

women aware of the increased lifetime risks of cardiovascular 

disease and/or diabetes.

Strong for Reviewed, 

New-added

Referral

14.

We suggest that pregnant women with an unexplained 

elevation of maternal serum alpha-fetoprotein be evaluated and 

counseled by a qualified obstetric provider due to increased risk 

for adverse perinatal outcomes.

Weak for Not reviewed, 

Amended

15. We recommend against routine screening for preterm delivery 

using the fetal fibronectin test in asymptomatic women.

Strong 

against

Not reviewed, 

Amended

16.

We recommend considering the use of fetal fibronectin testing 

as a part of the evaluation strategy in women between 24 and 

34 6/7 weeks gestation with signs and symptoms of preterm 

labor, particularly in facilities where the result might affect 

management of delivery.

Strong for Not reviewed, 

Amended
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March 2018 Page 6 of 40

# Recommendation Strength* Category†

Subpopulations

a. High Risk for

Preeclampsia

17.

In women at risk of preeclampsia, we recommend low dose 

(e.g., 100-150 mg daily) aspirin therapy initiated at or before 16 

weeks gestation.

Strong for Reviewed, 

New-added

b. High Risk for

Preterm Delivery

18.

We recommend antenatal progesterone therapy in consultation 

with an advanced prenatal care provider (e.g., obstetrician or 

maternal-fetal medicine) for women at high risk for recurrent 

preterm delivery and who meet the generally accepted inclusion 

criteria.

Strong for Not reviewed, 

Amended

c. Over 44

Years of Age

19.

We suggest offering women greater than 44 years of age 

planned delivery at 38 weeks gestational age to reduce the risk 

of stillbirth.

Weak for Reviewed, 

New-added

d. History of Bariatric Surgery

20.

We suggest that women who have undergone bariatric surgery 

should be evaluated for nutritional deficiencies and need for 

nutritional supplementation where indicated (e.g., vitamin B12, 

folate, iron, calcium).

Weak for Reviewed, 

New-replaced

21.

For pregnant women who have undergone bariatric surgery, 

there is insufficient evidence to recommend for or against the 

routine supplementation of vitamins A, D, E, or K.

N/A Reviewed, 

New-replaced

22.

We suggest that pregnant women with a history of gastric 

bypass surgery be evaluated by a surgeon with bariatric 

expertise.

Weak for Reviewed, 

Amended

*For additional information, please refer to the section below, as well as section on Grading Recommendations in the full 

text Pregnancy CPG.

Methods

†For additional information, please refer to the section below, as well as the section on Recommendation Categorization

and Appendix A in the full text Pregnancy CPG.

Methods
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III. Algorithm

This algorithm is designed to inform providers of the recommended interventions and appropriate 

timing of each of the interventions for women during pregnancy and in the postpartum period. The 

interventions included in the algorithm are paired with the corresponding recommendation in the 

VA/DoD Clinical Practice Guideline for the Management of Pregnancy. Following the algorithm, narrative 

sections, Standard of Pregnancy Care and Routine Pregnancy Care, provide additional information. 
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March 2018

 Page 8 of 40

A. Algorithm Key

Symbol Meaning

P Action to be carried out by provider 

R Referral needs to be made to an advanced prenatal care provider 

(e.g., obstetrician or maternal-fetal medicine) 

L Lab needs to be ordered 

Dotted Timing is not ideal, but it is still helpful for the pregnant woman to 

receive this action at this time (rather than not at all)

V1 First visit

PP Postpartum visit

B. Actions at Every Visit

At every visit, assess:

• Blood pressure

• Body mass index (BMI)

• Weight gain

• Medication reconciliation

• Need for consultation with advanced prenatal care provider (e.g.,

obstetrician or maternal-fetal medicine) for women at high risk for

preterm delivery (Recommendation 18)

Note: 

Please see the below sections Standard of Pregnancy Care and Routine 

Pregnancy Care.

C. Interventions by Weeks Gestation

Intervention

 Screen for intimate partner violencea 

 Screen for depression using standardized tool (e.g., EPDS, PHQ-9)a (Recommendation 6) 

 Screen for tobacco, alcohol, illicit drugs, and non-prescribed use of medication; if positive, 

recommend cessation and offer assistancea (Recommendation 5)

 Provide prenatal education (e.g., dental health, breastfeeding [Recommendation 7], exercise 

[Recommendation 2], weight gain, work schedules [Recommendation 3], dietary 

supplementation [Recommendation 4])b 

 Recommend influenza vaccination (seasonal) for mother and familyb 

 Screen for infectious diseases (GC/CT, HIV, syphilis, rubella, hepatitis B, varicella [if unsure], 

asymptomatic bacteriuria, TB, history of HSV); treat or manage as indicateda

 Screen for Rh status and anemia/hemoglobinopathies

 Evaluate for nutritional deficiencies in women who have undergone bariatric surgery with 

intervention as needed (Recommendation 20) 

 Consult with RDN for women who have undergone bariatric surgery and who are on a 

restrictive diet 

 Refer to bariatric surgeon women who have recently undergone gastric bypass surgery 

(Recommendation 22)

 Perform dating ultrasoundc (Recommendation 11)

 Offer group model of prenatal care (Recommendation 1)
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Weeks Gestation

First Trimester Second Trimester Third Trimester PP

V1

8 

12162024283236

4

Intervention

 Offer prenatal screening for aneuploidy and common genetic disorders (Recommendation 8

and Recommendation 9)

 Offer prenatal diagnostic testing for aneuploidy (accepted alternative to screening) 

 Initiate low dose aspirin therapy for women at risk of preeclampsia (Recommendation 17)

 Offer evaluation of MSAFP for pregnant women who did not have serum aneuploidy screening 

or who had non-invasive prenatal screening (Recommendation 14)

 Offer antenatal progesterone therapy in consultation with an advanced prenatal care provider 

(e.g., obstetrician or maternal-fetal medicine) for women at high risk for recurrent preterm 

delivery (Recommendation 18)

 Complete fetal anatomy ultrasound

 Measure fundal height

 Screen for GDM with one-hour GCT (for women with dumping syndrome, use fasting and twohour post-prandial glucose value)a (Recommendation 10)

 Perform fetal fibronectin test for women with signs/symptoms of preterm labor 

(Recommendation 16)

 Assess and educate regarding fetal movement/kick counts and preterm labor symptoms

 Recommend Tdap vaccination for mother and family

 Administer Rh immune globulin to Rh negative pregnant women

 Discuss family planning/contraception

 Screen for GBS 

 Initiate HSV prophylaxis if indicated

 Assess fetal presentation

 Assess and educate regarding fetal movement/kick counts and labor symptoms

 Offer scheduled delivery at 38 weeks for women greater than 44 years old (Recommendation 

19)

 Offer scheduled delivery or initiate antepartum fetal testing (Recommendation 12)

 Administer Rh immune globulin to Rh negative mothers with Rh positive babies

 Postpartum visit: Educate about lifetime risk of CVD and DM for women with GDM, HTN, 

and/or preeclampsia (Recommendation 13); review current vaccination status in accordance 

with CDC guidance; screen for type 2 diabetes if the patient had GDM

a Follow-up for positive screen or based on patient need

b Provide education at the initial visit and throughout the pregnancy as needed

c This is optimally performed in the first trimester; in the absence of a first trimester ultrasound, dating can be established by ultrasound alone up to 22 6/7 weeks

Abbreviations: CDC: Centers for Disease Control and Prevention; CVD: cardiovascular disease; DM: diabetes mellitus; EPDS: Edinburgh Postnatal Depression Scale; GBS: group B streptococcus; 

GC/CT: Neisseria gonorrhoeae/Chlamydia trachomatis; GCT: glucose challenge test; GDM: gestational diabetes mellitus; HIV: human immunodeficiency virus; HPV: human papillomavirus; HSV: herpes 

simplex virus; HTN: hypertension; MSAFP: maternal serum alpha-fetoprotein; PHQ-9: Patient Health Questionnaire-9; RDN: Registered Dietician Nutritionist; Rh: rhesus; TB: tuberculosis; Tdap: 

tetanus-diphtheria-acellular pertussis
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D. Standard of Pregnancy Care

Please note that some aspects of pregnancy care, although clinically important and part of the standard of 

pregnancy care, do not have sufficient high-quality evidence to support a stand-alone recommendation. In 

many cases, clinical studies assessing the efficacy of these standards of pregnancy care do not exist 

because they are determined to be routine actions and it would be unethical to withhold them from 

pregnancy women in order to conduct a clinical trial (e.g., administration of rhesus [Rh] immune globulin). 

This is true for actions that are to be completed at every visit ( ), certain screenings, 

and other time-sensitive care. 

Actions at Every Visit

a. Additional Information on Actions at Every Visit

Vital Signs

Vital signs, such as measuring blood pressure, calculating BMI, and weighing a pregnant woman at each 

prenatal visit, is the standard of care in VA, DoD, and in the community. High blood pressure in pregnancy 

may lead to life-threatening maternal and fetal outcomes. Routinely measuring blood pressure is useful in 

detecting and managing gestational hypertension, preeclampsia, and pre-existing hypertension in 

pregnant women. The United States Preventive Services Task Force (USPSTF) determined that the best 

strategy for preventing preeclampsia in pregnancy is early detection through routine blood pressure 

screening.[ ] 2 A pregnant woman’s blood pressure should be measured at every visit. 

Assessing weight and calculating BMI for pregnant women at every visit gives the provider an opportunity 

to offer interventions that can improve both obstetrical and neonatal outcomes. Women who are 

overweight or obese are at greater risk for adverse health conditions during the preconception, 

antepartum, and postpartum periods. Women with low BMI are also at risk for adverse maternal and 

neonatal outcomes. Inadequate weight gain is a risk factor for spontaneous abortion, preterm birth, fetal 

growth restriction, hypertensive disorders, and poor perinatal outcomes. Women with anorexia nervosa 

may be identified by a low initial BMI and/or inadequate antepartum weight gain.[ ] This screening is 

particularly important in the military and Veteran population, as studies have suggested that this 

population may be at greater risk for BMI-associated obstetrical complications.[ ] More information 

regarding recommended weight gain can be found in . 

3

4

Table 1 and Table 2

Table 1. Weight Gain Recommendations for Singletons [5] 

Pre-pregnancy Weight (BMI in kg/m2) Recommended Weight Gain

Underweight (BMI <18.5) 28-40 lbs

Normal Weight (BMI 18.5-24.9) 25-35 lbs

Overweight (BMI 25.0-29.9) 15-25 lbs

Obese (BMI ≥30.0) 11- 20 lbs

Abbreviations: BMI: body mass index; kg: kilogram(s); lbs: pounds; m: meter(s)
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Table 2. Weight Gain Recommendations for Women Pregnant With Twins [5] 

Pre-pregnancy Weight (BMI in kg/m2) Recommended Weight Gain

Underweight (BMI <18.5) 50-62 lbs

Normal Weight (BMI 18.5-24.9) 37-54 lbs

Overweight (BMI 25.0-29.9) 31-50 lbs

Obese (BMI ≥30.0) 25-42 lbs

Abbreviations: BMI: body mass index; kg: kilogram(s); lbs: pounds; m: meter(s)

Medication Reconciliation 

Medication reconciliation or review at every prenatal visit to screen for potentially teratogenic 

medications, newly prescribed medications since the last prenatal visit, over the counter medications, and 

supplements is standard of care. When multiple providers are co-managing a pregnant woman, as in the 

case of VA and some DoD pregnant women, it is important to identify, address, and document 

medications. The Centers for Disease Control and Prevention (CDC) has partnered with other federal 

agencies and non-federal partners to improve the health of women and babies by working to identify the 

safest treatment options for the management of common conditions before and during pregnancy.[6] 

Pregnant women, in collaboration with their trusted providers and pharmacists, are highly motivated to 

protect developing babies from potential harms of medication use during pregnancy while maintaining 

optimal health.[6] 

b. Screenings

Dental Care

Periodontal disease, although common during pregnancy, is both preventable and curable. While 

recommendations for treatment of periodontal disease cannot be endorsed specifically at this time for the 

purpose of decreasing adverse fetal and maternal pregnancy outcomes (e.g., preterm birth, low birth 

weight, pregnancy loss, preeclampsia, gestational diabetes mellitus [GDM]), several studies have shown 

there may be an association between periodontal disease and increased risk of adverse pregnancy 

outcomes.[7,8] Pregnancy is not a contraindication to most dental services, though some procedures 

requiring general anesthesia may be deferred to the postpartum period.[9] Oral health care is not only a 

component of a healthy pregnancy, but evidence suggests that most infants and young children acquire 

caries-causing bacteria from their mothers.[10] Routine dental care, including x-rays (with proper anatomic 

shielding) and periodontal therapy, along with good oral hygiene, should be encouraged throughout 

pregnancy.[10,11] 

Immunizations 

It is important that all pregnant and breastfeeding women are immunized according to current CDC

schedules for vaccination. Maternal immunizations decrease the risk of life- or fetus-threatening diseases 

during pregnancy. Pregnant women are relatively immunocompromised and can be severely affected by 

influenza and other infectious pathogens. Immunizations help protect the mother from infection. They 

also enhance passive immunity of infants to pathogens that cause life-threatening illnesses. Safe 

immunization options during pregnancy are available, namely: pertussis, influenza, varicella, and rubella. 

Some patients may have concerns about the safety of vaccination in pregnancy; therefore, providers 

should be well-versed in the safety and benefits of vaccine administration.
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• Pertussis: Also known as whooping cough, pertussis is a highly contagious bacterial disease that 

can cause coughing and difficulty breathing. Pertussis poses a significant burden on infants and 

can be very serious or deadly, especially in those younger than one year. Pregnant women 

should receive the Tdap (tetanus toxoid, reduced tetanus, diphtheria toxoid, and acellular 

pertussis) vaccine during each pregnancy to provide passive immunity to infants, who would not 

otherwise routinely receive it until two months of age.[12] Although a pregnant woman can 

receive the Tdap vaccine at any time during pregnancy, the optimal time to receive the vaccine 

is from 27-36 weeks gestation, maximizing maternal antibody response and passive antibody 

transfer to the newborn. Women who do not receive Tdap during pregnancy should receive the 

vaccine in the immediate postpartum period. Furthermore, all caregivers, family, or others who 

will have direct contact with the newborn should be immunized.[12] 

• Influenza: Women who acquire influenza during pregnancy may experience increased morbidity 

and even death, with a possible increased spontaneous abortion rate.[13] For this reason, all 

women who are pregnant during influenza season should receive the influenza vaccine (an 

inactivated virus). According to the CDC, influenza vaccination is safe for both the mother and 

the fetus, regardless of gestational age. The influenza immunization has also been proven to be 

protective to both the mother and her baby from influenza for several months after birth.[14] 

• Varicella: Women with varicella infection during pregnancy have a 10-20% risk of developing 

pneumonia, a significant risk factor for maternal mortality, which is estimated to be as high as 

40%.[15] In pregnancy, varicella may cross the placenta resulting in congenital or neonatal 

varicella infection. Maternal infection in the first half of pregnancy has been associated with 

congenital varicella syndrome.[16] Neonatal varicella zoster virus (VZV) infection is associated 

with a high neonatal death rate.[17] Routine screening for varicella should be conducted 

through obtaining the mother’s history. If there is a negative/uncertain history of prior disease 

or vaccination status, a varicella titer should be obtained. If the mother is non-immune, a 

vaccination should be offered during the postpartum period. The vaccine is contraindicated 

during pregnancy.[18,19] 

• Rubella: Infection in the first 16 weeks of pregnancy can cause miscarriage or congenital rubella 

syndrome (CRS).[20] Due to concerns about possible teratogenicity, the measles/mumps/rubella 

(MMR) vaccination is not recommended during pregnancy.[21,22] Women who are not immune 

to rubella should be vaccinated before leaving the hospital after delivery.

Infectious Diseases 

Screening for infectious diseases during pregnancy per current guidance from the CDC is recommended. 

Appropriate follow-up treatment and/or prophylaxis treatment depending upon the history, known 

exposure, and symptoms of infectious disease is necessary. This includes:

• Gonorrhea

• Chlamydia

• Syphilis

• Human immunodeficiency virus (HIV)
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• Hepatitis B virus

• Rubella

• Human papillomavirus virus (HPV) (if there is a history of an abnormal cervical screen) 

• Herpes simplex virus (HSV)

• Group B streptococcus (GBS)

Infectious diseases during pregnancy can cause significant mortality and morbidity in both the mother and 

the fetus. According to the CDC, screening for infectious diseases, counseling, and treatment can improve 

maternal and fetal outcomes.[23] 

GBS infections are the leading cause of serious neonatal infections (e.g., sepsis, meningitis, pneumonia) 

within the first seven days of life (early-onset infection). Universal screening at 35-37 weeks gestation with 

a single vaginal swab and intrapartum antibiotic prophylaxis continues to be the standard. 

Because new exposures and infectious agents can emerge (such as Zika virus), it is important to refer to 

the most recent CDC guidance. Screening can lead to diagnosis in asymptomatic women and allow 

pregnant women an opportunity to be treated. 

Vitamins

We suggest daily multivitamins to be taken starting one month before conception and continued 

throughout pregnancy and breastfeeding. Women in the U.S. commonly supplement their diet with 

vitamins and minerals during pregnancy. Supplementation with individual vitamins and minerals such as 

folate, as well as with multivitamins, has been associated with improved outcomes. See Recommendation 

4 for additional information on folate supplementation. Supplementation with multivitamins was found to 

lower the risk of preeclampsia and three forms of childhood cancer (pediatric brain tumors, 

neuroblastomas, and leukemia).[24,25] The Operation Supplement Safety website (www.opss.org) 

provides additional information that may be useful for patients regarding use of supplements during 

pregnancy and lactation, as well as information for women who may not be pregnant but who are 

planning to become pregnant or are of childbearing age.[26,27] 

Nutrition

We suggest that pregnant women on restrictive diets (e.g., vegetarians, bariatric surgery) consult with a 

dietitian. Though there is no consensus on the necessary requirements for patients both pre- and postbariatric surgery, it is a generally accepted standard of practice for surgeons and dietitians to follow up 

with these patients to monitor for surgical complications as well as nutritional adequacy and any potential 

deficiencies associated with the procedure. In addition to post-bariatric pregnant women, others with 

higher risk of nutritional complications include those who:

• Are vegetarian or vegan

• Avoid certain foods (e.g., due to food allergies, cultural reasons, fad diets)

• Are breastfeeding while pregnant

• Are underweight with a BMI <18.5 kg/m2
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• Are <17 years old

• Have a multiple gestation pregnancy

• Have a history of hypertension, hyperlipidemia, diabetes mellitus (DM), or GDM

• Have an eating disorder

• Are identified as food insecure (food insecurity is defined by the U.S. Department of Agriculture 

as a household-level economic and social condition of limited or uncertain access to adequate 

food [28])

The Academy of Nutrition and Dietetics (AND) recommends screening for the aforementioned nutritional 

risks and subsequent assessment by a Registered Dietitian Nutritionist (RDN) to evaluate the pregnant 

woman for nutritional adequacy during this phase of life.[29] Appointments with RDNs may not be feasible 

at all locations but tele-medical nutrition therapy may be a cost-effective option in some instances. 

Intimate Partner Violence 

Intimate partner violence (IPV) is a high-prevalence and high-risk problem that may be first identified 

during pregnancy, therefore routine screening during pregnancy is indicated. Risks of IPV during pregnancy 

include preterm birth, low birth weight, and decreased gestational age. In addition, a history of IPV is 

associated with higher rates of chronic pain, neurologic disorders, gastrointestinal disorders, and 

psychiatric disorders.[30] Although there is strong evidence for the utility of screening, there is no 

evidence regarding optimal screening times or intervals.

The 5-item Extended - Hurt, Insult, Threaten, Scream (E-HITS) tool has been found to be an effective 

screening method, with high levels of sensitivity and specificity.[30,31] The items are included below.

In the past year, how often did a current or former intimate partner (e.g., boyfriend, girlfriend, wife, 

husband, sexual partner): 

1. Physically hurt you

2. Insult or talk down to you

3. Threaten you with harm

4. Scream or curse at you

5. Force you to have sexual activities 

Responses for each item are on a 5-point scale: Never (1), Rarely (2), Sometimes (3), Often (4), 

Frequently (5). A score of 7 or higher is considered positive for IPV, with clinician judgment 

recommended for a score of 6. 

For women who screen positive, we recommend completing an assessment and providing information, 

intervention, and/or referrals as needed. 
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c. Time Sensitive Care

Fetal Anatomy Scan

We suggest offering a complete fetal anatomy ultrasound to all pregnant women. Optimal timing of this 

complete fetal anatomy ultrasound is in the second trimester between 18 and 22 weeks of 

gestation.[32,33] Routine screening provides a more accurate gestational age assessment (with 

subsequent lower incidence of induction for post-term pregnancy), earlier detection of multiple 

gestations, and greater detection of unsuspected fetal abnormalities (with subsequent increased 

terminations).[34] A complete obstetric sonographic examination should be available to all women, 

including those considering an invasive test.[35,36] 

Fetal Presentation

Fetal presentation should be assessed at 36 weeks gestation in order to determine the need for further 

treatment.[37] If non-cephalic presentation is suspected, it should be confirmed with ultrasound.[38] Once 

confirmed, a consultation with the appropriate obstetrical provider should be made immediately to 

discuss external cephalic version to correct malpresentation.[39,40] Potential benefits of appropriate 

management of pregnancy would include improved vaginal delivery rates and decreased maternal harm 

from cesarean delivery. 

Postpartum Visit

All women should have a postpartum visit, optimally within six weeks, and no later than eight weeks, after 

delivery. Postpartum follow-up is specifically encouraged for women who experienced complications 

during pregnancy, such as hypertensive diseases, gestational and non-gestational DM, and depression. 

Women with a history of GDM are at increased risk of developing type 2 DM. See the VA/DoD Clinical 

Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care for more information 

on diagnostic techniques.3 Women with hypertensive and metabolic diseases of pregnancy may have 

increased risk of long-term health problems, particularly lifetime risk of cardiovascular disease. Thus, more 

accurate diagnosis of conditions such as impaired glucose tolerance has become even more crucial. The 

obstetric provider should begin the implementation of an individual risk-based surveillance strategy at 

the postpartum visit, which can be transitioned to the woman’s long-term primary care provider. 

Benefits to the mother may include early identification of health conditions and early initiation of 

appropriate management methods. During this postpartum visit the provider may also assess 

contraception initiation, breastfeeding, and mental health disorders. 

d. Summary

These assessments and care management methods, including actions completed at every visit, 

screenings, and time sensitive care, have become the standard of pregnancy care. When combined, all 

of these factors will help providers determine the appropriate management of pregnancy, potentially 

including a consult to an advanced prenatal care provider (e.g., obstetrician or maternal-fetal medicine) 

or another referral as indicated. 

 

3 See the VA/DoD Clinical Practice Guideline for the Management of Type 2 Diabetes Mellitus in Primary Care. Available at: 

https://www.healthquality.va.gov/guidelines/cd/diabetes/ 
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IV. Routine Pregnancy Care

The CPG does not address every aspect of routine care. The below information can be used to help 

guide clinicians during the routine aspects of management of pregnancy. An initial prenatal risk 

assessment checklist, which can be used to help guide the initial prenatal care appointment and next 

steps, is included in Table 3. Consideration of antepartum referrals to advanced prenatal care providers 

can be informed by Table 4. 

Table 3. Initial Prenatal Risk Assessment Checklist

Risk Factors

Nurse 

Assessment via 

Questionnaire Suggested Action

Dating

Uncertain dating criteria √ Dating ultrasound

Late presentation √ Dating ultrasound

Current 

Issues

Vaginalbleeding √ Immediate evaluation

Significantabdominalpain/cramping √ Immediate evaluation

Dental complaint √ Refer to dental

Past Obstetrical History

Recurrent pregnancy loss √ Refer to infertility specialist or reproductive 

endocrinologist

Risk of ectopic pregnancy (prior

ectopic pregnancy, prior tubal surgery,

current intrauterine device, history of

tubal infertility or pelvic inflammatory 

disease)

√

Refer for evaluation and ultrasound 

(immediate referral if having bleeding or 

pain; scheduled referral if asymptomatic)

Prior macrosomia or prior GDM √ Obtain early one-hour GCT

Prior pretermdelivery √ Refer to obstetrician/gynecologist or 

maternal fetal medicine provider

Prior second-trimesterpregnancy loss √ Refer to maternal fetal medicine provider

Prior preeclampsia √ Refer to obstetrician/gynecologist or 

maternal fetal medicine provider

Prior stillbirth √ Refer to obstetrician/gynecologist or 

maternal fetal medicine provider

Prior isoimmunization affected 

pregnancy

√ Refer to maternal fetal medicine provider

Cervicalsurgery (loop electrical 

excision procedure, cone biopsy) or 

uterine anomaly

√ Refer to obstetrician/gynecologist or 

maternal fetal medicine provider

Prior uterine surgery (myomectomy, 

metroplasty) √ Refer to obstetrician/gynecologist or maternal fetal medicine provider

Bariatric surgery lessthan 18 months 

ago

√

Refer to nutrition,

obstetrician/gynecologist, or maternal fetal 

medicine provider

Prescription or over-the-counter 

medications or herbalsupplements √ Refer to maternal fetal medicine based on teratogen risk

Drug/alcohol use √ Refer to maternal fetal medicine provider

Tobacco product use √ Document, educate
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March 2018 Page 17 of 40

Risk Factors

Nurse 

Assessment via 

Questionnaire Suggested Action

Medical Conditions/ History

Neurological disorder √ Refer to maternal fetal medicine provider, 

neurology

CVD, cardiac anomaly √ Refer to maternal fetal medicine provider, 

cardiology

Hypertension √

Refer to obstetrician/gynecologist or 

maternal fetal medicine provider, 

cardiology

Pulmonarydisease √ Refer to maternal fetal medicine provider, 

pulmonology

Renal disorder (includes

pyelonephritis) √ Refer to maternal fetal medicine provider, nephrology

DM (Type 1 or 2) √

Refer to maternal fetal medicine provider, 

endocrinology 

Obtain HbA1C

Family history of DM in first relative √ Obtain early one-hour GCT

Thyroid disorders √ Obtain thyroid function tests

Autoimmunedisorders (lupus, 

rheumatoid arthritis, antiphospholipid syndrome)

√ Refer to maternal fetal medicine provider, 

rheumatology

Bleeding disorder √ Refer to maternal fetal medicine provider, 

hematology

Clotting disorder √ Refer to maternal fetal medicine provider, 

hematology

Gastrointestinaldisorderson

medications √ Refer to maternal fetal medicine provider, gastroenterology

Sickle cell anemia or carrier √

Refer to maternal fetal medicine provider, 

hematology, genetic counselor

Hemoglobin electrophoresis if not done for 

patient and partner

Cystic fibrosis carrier status √ Refer to maternal fetal medicine provider, 

genetic counselor

History of genetic disease or family

history of genetic disease √ Refer to maternal fetal medicine provider, genetic counselor

Prior infant with congenital birth 

defect √ Refer to maternal fetal medicine provider

Hepatitis √

Refer to maternal fetal medicine provider, 

gastroenterology

Pertinent hepatitis labs, liver function tests

Positive screen for sexually transmitted 

infection √ Refer to provider and take appropriate 

action depending on infection

Tuberculosis or received Bacillus 

Calmette–Guérin vaccine √ Chest x-ray

HIV √ Refer to maternal fetal medicine provider, 

infectious disease

Rash or viral illness √ Serology for suspected infection
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Risk Factors

Nurse 

Assessment via 

Questionnaire Suggested Action

Medical Conditions/ History (cont.)

Radiation/toxic chemical exposure

since becoming pregnant

√ Refer to maternal fetal medicine provider

Cancer (current or recent) √ Refer to maternal fetal medicine provider

Transplant √ Refer to maternal fetal medicine provider

Current or prior depression √

Refer to behavioral health if suicidal or

moderate or severe MDD, unless has 

established care

Other mental illness (e.g., anxiety, 

bipolar, schizophrenia) on or off 

medications

√ Refer to behavioral health unless has 

established care

Deployment related PTSD and/or 

military sexual trauma √ Refer to behavioral health unless 

established care

Occupational hazards or exposures √

Refer to occupational health, 

Refer to maternal fetal medicine provider if 

teratogen 

Homeless √ Refer to socialservices

Intimate partner violence √ Refer to social services

History of infertility √ Perform transvaginal ultrasound, if not 

already done

Diet restriction (e.g., previous 

bariatric surgery, vegan, vegetarian) √ Refer to nutrition

Eating disorder √ Refer to behavioral health

BMI <16.5 or >30 kg/m2 √ Obtain early one-hour GCT if BMI >30 kg/m2

Refer to nutrition

Age (<16 or >35 years) √ Refer to advanced prenatal provider

Additional Information

Currently or previously deployed or

family member √ Refer to social work if desired

Previous deployment (self) √ Document

Lives with cats; educate about not 

changing litter box √ Educate

Eating undercooked meat, highmercury fish, unpasteurized foods √ Educate

Seat belt usage √ Educate

Planned pregnancy √ Document

Born outside the U.S. √ Document

Primary language other than English √ Document

Religious preference √ Document

Highest level of education √ Document

Preferred method of learning √ Document
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 19 of 40

Risk Factors

Nurse 

Assessment via 

Questionnaire Suggested Action

Routine Lab Tests

HIV Lab

Complete blood count Lab

ABO Rh blood typing Lab

Antibody screen Lab

Rapid plasma reagin Lab

Hepatitis B surface antigen test Lab

Rubella IgG Lab

Urinalysis and culture Lab

Varicella IgG if status unknown Lab

Abbreviations: BMI: body mass index; CVD: cardiovascular disease; DM: diabetes mellitus; GCT: glucose challenge test; GDM: 

gestational diabetes mellitus; HbA1C: glycosylated hemoglobin A1c; HIV: human immunodeficiency virus; IgG: immunoglobulin G; 

kg: kilogram(s); m: meter(s); MDD: major depressive disorder; PTSD: posttraumatic stress disorder; Rh: rhesus; U.S.: United States

Table 4. Potential Indications for Referral to an Advanced Prenatal Care Provider

Risk Assessed or Identified by Routine Prenatal Care Provider

Obstetric Complications

Short (<2.5 cm) cervix (<24 weeks)

Malpresentation (>36 weeks)

Placenta previa (symptomatic or beyond 28 weeks)

Abnormal amniotic fluid: oligo/polyhydramnios

Preterm premature rupture of membranes

Fetal growth abnormality (estimated fetal weight >5,000 g) 

Known or suspected fetal anomaly

Multiple gestation

Isoimmunization

Abnormal prenatal screening result (aneuploidy risk, open NTD, carrier screen)

Intrauterine fetal demise

Prior cesarean section

Gynecologic, Medical,

and Surgical Conditions

Current need for surgery

Hematologic disorders (except physiologic anemia)

Abnormal pap smear

Prior uterine surgery (myomectomy)

Breast abnormality

Illicit drug or alcohol

TORCH infection

*Referral depends upon local availability of resources and comfort of individual care provider

Abbreviations: cm: centimeter(s); g: gram(s); NTD: neural tube defect; TORCH: toxoplasmosis, other (syphilis, varicella-zoster, 

parvovirus B19), rubella, cytomegalovirus (CMV), and herpes infections
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

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V. Scope of the CPG

Regardless of setting, any patient in the healthcare system should ideally have access to the interventions 

that are recommended in the 2018 Pregnancy CPG after taking into consideration the patient’s specific 

circumstances. Guideline recommendations are intended to be patient-centered. Thus, treatment and care 

should take into account a patient’s needs and preferences. Good communication between healthcare 

professionals and the patient is essential and should be supported by evidence-based information tailored 

to the patient’s needs. Use of an empathetic and non-judgmental approach facilitates discussions sensitive 

to gender, culture, ethnic, and other differences. The information that patients are given about treatment 

and care should be culturally appropriate and also available to people with limited literacy skills. It should 

also be accessible to people with additional needs such as physical, sensory, or learning disabilities. Family 

involvement should be considered, if appropriate.

This CPG is designed to assist providers in managing or co-managing pregnant women as well as cooccurring conditions. Moreover, the patient population of interest for this CPG is pregnant women who 

are eligible for care in the VA and DoD healthcare delivery systems. It includes Veterans as well as 

deployed and non-deployed Active Duty Service, Guard, and Reserve Members and their dependents. 

This CPG is based on information available through May 2017. The systematic review conducted for this 

CPG update targeted 10 key questions (KQs) focusing on the means by which the delivery of healthcare 

could be optimized for pregnant women. The selected KQs were prioritized by the Work Group from many 

possible KQs based on consensus as to their level of importance. Due to resource constraints, an extensive 

review of the evidence for all important aspects of care was not feasible for the update to this CPG. 

VI. Methods

The 2018 Pregnancy CPG is an update to the 2009 Pregnancy CPG. The methodology used in developing 

the 2018 CPG follows the Guideline for Guidelines,[1] an internal document of the VA and DoD EBPWG. 

The Guideline for Guidelines can be downloaded from http://www.healthquality.va.gov/policy/index.asp. 

The guideline development process for the 2018 CPG update consisted of the following steps: formulating

and prioritizing KQs, convening patient focus groups, conducting the systematic evidence review, 

convening a face-to-face meeting with the CPG Champions and Work Group members, and drafting and 

submitting a final CPG on the management of pregnancy to the VA/DoD EBPWG. 

The Champions and Work Group used the Grading of Recommendations Assessment, Development and 

Evaluation (GRADE) system to assess the quality of the evidence base and assign a strength for each 

recommendation. The GRADE system uses the following four domains to assess the strength of each 

recommendation:[25] 

• Balance of desirable and undesirable outcomes 

• Confidence in the quality of the evidence 

• Patient or provider values and preferences

• Other implications, as appropriate, e.g.,:

 Resource use
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 Equity

 Acceptability

 Feasibility

 Subgroup considerations

Using these four domains, the Work Group determined the relative strength of each recommendation 

(“Strong” or “Weak”). A “Strong” recommendation generally indicates a high confidence in the quality of 

the available scientific evidence, a clear difference in magnitude between the benefits and harms of an 

intervention, similar patient or provider values and preferences, and understood influence of other 

implications (e.g., resource use, feasibility). If the Work Group has less confidence after the assessment 

across these domains and believes that additional evidence may change the recommendation, it generally 

assigns a “Weak” recommendation. It is important to note that the GRADE terminology used to indicate 

the assessment across the four domains (i.e., Strong vs. Weak) should not be confused with the clinical 

importance of the recommendation. A weak recommendation may still be important to the clinical care of 

a pregnant patient. 

Occasionally, instances may occur when the Work Group feels there is insufficient evidence to make a 

recommendation for or against a particular therapy or preventive measure. This can occur when there is 

an absence of studies on a particular topic that met evidence review inclusion criteria, studies included in 

the evidence review report conflicting results, or studies included in the evidence review report 

inconclusive results regarding the desirable and undesirable outcomes. 

Using these elements, the grade of each recommendation is presented as part of a continuum:

• Strong for (or “We recommend offering this option ...”)

• Weak for (or “We suggest offering this option ...”)

• No recommendation for or against (or “There is insufficient evidence...”)

• Weak against (or “We suggest not offering this option ...”)

• Strong against (or “We recommend against offering this option ...”)

The grade of each recommendation made in the 2018 CPG can be found in the section on 

Recommendations. Additional information regarding the use of the GRADE system can be found in 

Appendix A in the full Pregnancy CPG. 

The Work Group developed both new and updated recommendations based on the evidence review 

conducted for the priority areas addressed by the KQs. In addition, the Work Group considered, without 

complete review of the relevant evidence, the current applicability of other recommendations that were 

included in the 2009 Pregnancy CPG, subject to evolving practice in today’s environment. A set of 

recommendation categories was adapted from those used by the National Institute for Health and Care 

Excellence (NICE).[41,42] These categories, along with their corresponding definitions, were used to 

account for the various ways in which recommendations could have been updated from the 2009 

Pregnancy CPG. The categories and definitions can be found in Table 5. 
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Table 5. Recommendation Categories and Definitions 

Evidence 

Reviewed*

Recommendation 

Category* Definition*

Reviewed

New-added New recommendation following review of the evidence

New-replaced Recommendation from previous CPG that has been carried over to the 

updated CPG that has been changed following review of the evidence

Not changed

Recommendation from previous CPG that has been carried forward to the 

updated CPG where the evidence has been reviewed but the 

recommendation is not changed

Amended

Recommendation from the previous CPG that has been carried forward to 

the updated CPG where the evidence has been reviewed and a minor 

amendment has been made

Deleted Recommendation from the previous CPG that has been removed based on 

review of the evidence

Not 

reviewed

Not changed Recommendation from previous CPG that has been carried forward to the 

updated CPG, but for which the evidence has not been reviewed

Amended

Recommendation from the previous CPG that has been carried forward to 

the updated CPG where the evidence has not been reviewed and a minor 

amendment has been made

Deleted Recommendation from the previous CPG that has been removed because it 

was deemed out of scope for the updated CPG

*Adapted from the NICE guideline manual (2012) [41] and Garcia et al. (2014) [42] 

Abbreviation: CPG: clinical practice guideline
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

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VII. Guideline Work Group

Guideline Work Group*

Department of Veterans Affairs

Heather Able, MSN, RNC (Champion)

Alicia Christy, MD, MHSCR, FACOG (Champion)

Grace Chang, MD, MPH

Megan Gerber, MD, MPH

Barbara J. Hector, WHNP

Carrie Kairys, DNP, FNP-BC

Jacqueline H. Langston, BSN, RN, CNM

Laura J. Miller, MD

Ki Park, MD, MS, FSCAI

Deanna Rolstead, MD, FACOG

Department of Defense

COL Lisa Foglia, MD, FACOG (Champion)

Lt Col Barton Staat, MD, FACOG (Champion)

CPT Allison M. DeLuca, CNM, RN

Maj Minette Herrick, MS, RDN, IBCLC

LT Karla Krasnoselsky, DPT, CSCS

MAJ Sheila A. Medina, DNP, FNP-C

COL Cynthia Sanchez, MSN, RN

CDR Robert Selvester, MD

Kristi Shearer, PhD

Elaine P. Stuffel, BSN, RN, MHA

CDR Christopher Tatro, MD, FACOG

Office of Quality, Safety and Value 

Veterans Health Administration

M. Eric Rodgers, PhD, FNP-BC

James Sall, PhD, FNP-BC

Rene Sutton, BS, HCA

Office of Evidence Based Practice

U.S. Army Medical Command

Corinne K. B. Devlin, MSN, RN, FNP-BC

Elaine P. Stuffel, BSN, RN, MHA

The Lewin Group

Clifford Goodman, PhD

Christine Jones, MS, MPH, PMP

Erika Beam, MS

Anjali Jain, MD

Nicolas Stettler-Davis, MD, MSCE

ECRI Institute

Kristen D’Anci, PhD

James Reston, PhD, MPH

Jeff Oristaglio, PhD

Amy Tsou, MD

Gina Giradi, MS

Michele Datko, MLS

Sigma Health Consulting, LLC Frances Murphy, MD, MPH

DutyFirst Consulting Anita Ramanathan, BA

Megan McGovern, BA

*Additional contributor contact information is available in Appendix E in the full CPG. 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

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VIII. Patient-centered Care

VA/DoD CPGs encourage clinicians to use a PCC approach that is individualized based on patient 

capabilities, needs, goals, prior treatment experience, and preferences. Regardless of setting, all patients in 

the healthcare system should be offered access to evidence-based interventions appropriate to that 

patient. When properly executed, PCC may decrease patient anxiety, increase trust in clinicians,[43] and 

improve treatment adherence.[44] Improved patient-clinician communication through PCC can be used to 

convey openness to discuss any future concerns. 

As part of the PCC approach, clinicians should review the outcomes of previous healthcare experiences 

with the pregnant woman. Additionally, they should involve the patient in prioritizing rehabilitation goals 

and setting specific goals regardless of the selected setting or level of care. 

Healthcare coverage may factor into a pregnant woman’s decision making process regarding her care. 

However, healthcare coverage for each woman may vary. Therefore, it may be helpful for pregnant 

women to discuss their coverage with the appropriate VA or DoD representative. Pregnant women who 

obtain their healthcare coverage through the VA should talk to their Maternity Care Coordinator. Pregnant 

women who obtain their healthcare coverage through the DoD should talk to their TRICARE 

representative. 

IX. Shared Decision Making

Throughout this VA/DoD CPG, the authors encourage clinicians to focus on shared decision making (SDM). 

The SDM model was introduced in Crossing the Quality Chasm, an Institute of Medicine (IOM) (now called 

the National Academy of Medicine [NAM]) report, in 2001.[45] It is readily apparent that pregnant women, 

together with their clinicians, make decisions regarding their plan of care and management options. 

Pregnant women require sufficient information and time to be able to make informed decisions. Clinicians 

must be adept at presenting information to their patients regarding individual treatments, expected 

outcomes, and levels and/or locations of care. During pregnancy, this includes presenting the mother, and 

her support system as appropriate, information about maternal and fetal risks of untreated symptoms and 

maternal and fetal benefits and risks of proposed care. Clinicians are encouraged to use SDM to 

individualize treatment goals and plans based on patient capabilities, needs, goals, prior pregnancy 

experience, and preferences.

X. Discussion of Recommendations

A. Care Throughout Pregnancy

a. Routine Care During Pregnancy

1. We suggest offering a group model of prenatal care as an acceptable alternative to individual 

provider appointments. (Weak for; Not reviewed, Amended)

• A recent meta-analysis of group prenatal care versus traditional prenatal care did not find 

significant benefits to group prenatal care over traditional prenatal care.[46] However, there 

was no evidence of harm and other outcomes such as patient satisfaction, contraception 

initiation, and depression were not examined. 
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March 2018 Page 25 of 40

• One study demonstrated that women assigned to group prenatal care were less likely to 

experience preterm delivery than those receiving standard prenatal care.[47]

• A group model may fit better with the values and preferences of some pregnant woman than 

the individual model. 

2. We recommend that all healthy, pregnant women without known contraindications participate in 

regular mild to moderate exercise sessions, three or more times per week. (Strong for; Reviewed, 

Amended)

• Moderate level evidence shows that healthy pregnant women benefit most from completing at 

least 150 minutes per week of mild to moderate intensity exercise, with limited risk to mother 

and baby.[48] Studies included in the evidence review overwhelmingly used three or more 

sessions per week.[48-53]

• Exercise can reduce excess maternal weight gain, incidence of fetal macrosomia in newborns, 

and rates of neonatal respiratory distress, GDM, depression, and cesarean deliveries.[48-55] 

There is no evidence to suggest that exercise causes preterm births, underweight newborns, 

stillbirths, or increased incidence of shoulder dystocia or induction of labor.[48-55]

• Women should be educated on how to calculate or identify mild to moderate intensity to better 

recognize exercises that are right for them. Estimation can include percentage of heart rate, 

metabolic equivalent levels, and the Borg Rate of Perceived Exertion.[56] Further information 

on exercise intensity can be found in the VA/DoD Clinical Practice Guideline for Screening and 

Management of Obesity and Overweight4 and through the CDC website5

.

• Women with healthy pregnancies can continue their pre-pregnancy exercise routine throughout 

pregnancy. Previously sedentary women can slowly start a new exercise routine during 

pregnancy, consisting of aerobic exercise and strength training, without increase risk.[48] 

• Medical conditions that may warrant referral for a supervised exercise program include 

moderate or severe anemia, preeclampsia, gestational hypertension, poorly controlled chronic 

hypertension, unevaluated maternal cardiac arrhythmia, chronic bronchitis, poorly controlled 

type 1 DM, extreme morbid obesity, extreme underweight (BMI <12 kg/m2

), extremely 

sedentary lifestyle, fetal growth restriction in current pregnancy, orthopedic limitations, poorly 

controlled seizure disorder, poorly controlled hyperthyroidism, and heavy smoking.[55] 

3. We suggest that women with uncomplicated pregnancies continue a standard work schedule 

throughout their pregnancy. (Weak for; Not reviewed, Amended)

• Physically demanding work and prolonged standing (more than three hours at a time with little 

movement) increases risk for preterm birth and hypertension or preeclampsia.[57-60] Thus, if a 

pregnant women’s work is strenuous (e.g., involves industrial machines, requires significant 

physical exertion), she should limit her work week to 40 hours and workday to eight hours 

during the last trimester or earlier if she frequently experiences symptoms of preterm labor. 

 

4 See the VA/DoD Clinical Practice Guideline for Screening and Management of Obesity and Overweight. Available at: 

https://www.healthquality.va.gov/guidelines/cd/obesity/ 5 The Centers for Disease Control and Prevention website on physical activity is available at: 

https://www.cdc.gov/physicalactivity/index.html. 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 26 of 40

• Active Duty Service Members should continue to follow their service-specific profiling 

regulations. 

b. Nutrition

4. We recommend folic acid (at least 400 micrograms daily) to be taken starting one month before 

conception and continued throughout pregnancy and breastfeeding. (Strong for; Not reviewed, 

Amended)

• Neural tube defects (NTDs), one of the most common major congenital anomalies in the U.S., 

occur at a very early gestational age. Studies have found that preconception folic acid 

supplements, either alone or combined with other vitamins or minerals (e.g., in a multivitamin), 

reduces risk of NTDs and should be continued through the first trimester.[61-63] Folic acid 

supplementation has not been found to be associated with serious harms.[64,65] 

c. Screening

5. We recommend screening for use of tobacco, alcohol, illicit drugs, and unauthorized use of 

prescription medication because their use is common and can result in adverse outcomes. For 

women who screen positive, we recommend additional evaluation and treatment (see VA/DoD 

Clinical Practice Guidelines for the Management of Substance Use Disorders6 and the Management 

of Tobacco Use7

). (Strong for; Reviewed, Amended)

• Prenatal exposure to substances may increase the risk of congenital anomalies and long-term 

adverse effects.

• Smoking may limit fetal growth leading to low birth weight, reduced birth length, or head 

circumference.[66] 

• Alcohol is a known teratogen and leads to abnormalities with the head, kidney, liver, 

gastrointestinal tract, endocrine system, and brain.[67] 

• Risks of prenatal cannabis exposure are unknown.[66] 

• Prenatal codeine, methadone, or heroin use has been found to be associated with a higher 

incidence of congenital abnormalities.[106] 

• Prenatal use of opioids is associated with neonatal abstinence syndrome (symptoms of central 

nervous system irritability, gastrointestinal dysfunction, and temperature instability).[68] 

• Due to the harm associated with substance use, screening for tobacco, alcohol, illicit drugs, and 

non-prescribed use of medication is recommended, followed by additional evaluation and 

treatment based on screening results. 

 

6 See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Available at: 

https://www.healthquality.va.gov/guidelines/mh/sud/ 7 See the Clinical Practice Guideline for the Management of Tobacco Use. Available at: 

https://www.healthquality.va.gov/CPGArchives.asp 
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6. We recommend screening for depression using a standardized tool such as the Edinburgh Postnatal 

Depression Scale or the 9-item Patient Health Questionnaire periodically during pregnancy and 

postpartum. (Strong for; Reviewed, New-replaced)

• Moderate quality evidence suggests that screening pregnant and postpartum women for 

depression using a validated screening tool is more effective than usual clinical assessment in 

detecting depression and in reducing depressive symptoms, particularly when done with access 

to interventions such as treatment protocols, care management, and trained clinicians.[69] 

Providers should screen patients periodically, such as at first presentation, week 28, and at the 

postpartum visit.

• Given the high prevalence of perinatal depression, adverse maternal and offspring effects of 

untreated perinatal depressive symptoms, and low rates of detection and treatment entry in the 

absence of screening, the benefits of screening were determined to outweigh any harms.

• The Edinburgh Postnatal Depression Scale (EPDS) and the 9-item Patient Health Questionnaire 

(PHQ-9) are among the screening tools which have been validated for perinatal use.

• Using depression screens may not detect other perinatal psychiatric disorders, such as bipolar 

disorder, anxiety disorders, or posttraumatic stress disorder (PTSD). It is important to have other 

methods in place to detect these disorders. Screening is not necessary for pregnant women who 

have already been diagnosed with a psychiatric disorder and are engaged in mental health 

treatment.

d. Education

7. We recommend breastfeeding education, assessment, and support to all pregnant women and their 

families at the first visit and throughout the pregnancy and postpartum period using open-ended 

questions such as “What do you know about breastfeeding?” (Strong for; Reviewed, New-replaced)

• The World Health Organization (WHO) recommends initiation of breastfeeding within the first 

hour of life and exclusive breastfeeding for at least six months.[70] Breastfeeding has been 

shown to lower the risk of type 2 DM, certain types of breast cancer, and ovarian cancer in 

mothers and asthma, childhood leukemia, and type 2 DM in children.[71,72] 

• Education about breastfeeding should start prenatally (ideally at the first visit), be continued 

throughout the pregnancy, include the pregnant woman’s family or chosen support people, and 

be tailored to the needs and resources of the community.

• Breastfeeding assessment in the prenatal period should include breast examination to screen 

for potential breastfeeding challenges, such as those related to inverted or “flat” nipples, history 

of breast augmentation or reduction, suspected breast hypoplasia or insufficient glandular 

tissue, past breastfeeding experience/perceptions, use of medications known to interfere with 

milk production, basic education pertaining to the benefits of breastfeeding and local resources 

and support programs available. As indicated, pregnant women should be referred to a certified 

lactation consultant (as available) for additional lactation support and education. 
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B. One-time Interventions

a. Screening and Diagnostic Testing

8. We suggest making prenatal diagnostic testing for aneuploidy available to all pregnant women. 

(Weak for; Reviewed, New-replaced)

• There are no RCTs or systematic reviews evaluating the overall benefits of offering prenatal 

diagnostic testing to all pregnant women. The Work Group’s confidence in the quality of the 

evidence is low, except regarding risk of pregnancy loss with procedures for which the 

confidence in the quality of the evidence is high.

• The benefits of invasive prenatal diagnostic testing include improving the ability to plan and to 

make more informed pregnancy and birth management decisions.

• Pregnant women considering invasive prenatal diagnostic testing should be counseled about the 

risks, benefits, limitations, and alternatives to invasive testing by a provider qualified to conduct 

this counseling.[73] 

9. We recommend offering prenatal screening for aneuploidy and the most common clinically 

significant genetic disorders to all pregnant women. When aneuploidy screening is desired, cell-free 

fetal DNA screening should be considered; however, screening test selection should be 

individualized and take into account the patient’s age, baseline aneuploidy risk, and test 

performance for a given condition. (Strong for; Reviewed, New-replaced)

• Benefits of testing are that, if the testing is positive, women have time to become educated 

about having a child with a genetic disorder and consult with providers who may be involved in 

the care of their child. Benefits may be greatest for women who are at high risk of aneuploidy 

(e.g., greater maternal age).

• There are multiple aneuploidy screening tests available. Each test’s performance has different 

sensitivity, specificity, and positive and negative predictive values, which are affected by the a 

priori risk of a given aneuploidy based on maternal age. Resource use also varies between tests.

• Cell-free fetal DNA (cffDNA) screening has the highest sensitivity and specificity of the available 

screening tests for Down syndrome in high risk women.[74-79] The test also screens for trisomy 

18 and trisomy 13, but has lower detection rates for these conditions. 

• Adequate pre-test counseling is required for all aneuploidy screening tests. The ability to 

provide post-test counseling for pregnant women who screen negative, as well as the 

availability of timely post-test counseling and diagnostic prenatal testing for pregnant women 

who screen positive, is necessary.

10. We suggest the two-step process (one-hour oral glucose challenge test followed by three-hour oral 

glucose tolerance test) to screen for gestational diabetes mellitus at 24-28 weeks gestation for all 

pregnant women. (Weak for; Reviewed, New-replaced)

• Pregnant women with GDM are at increased risk for developing fetal macrosomia and requiring 

operative delivery. Uncontrolled or poorly controlled GDM may also lead to neonatal morbidity, 

such as hypoglycemia, polycythemia, and hyperbilirubinemia. Early, appropriate treatment may 

lead to a reduction in hypertensive disorders in pregnancy, a decrease in cesarean deliveries, 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 29 of 40

and a decrease in macrosomia.[80] Therefore, any pregnant woman with GDM should have 

additional surveillance and management beyond the scope outlined in this guideline.

• For most women, screening for GDM should be undertaken at 24-28 weeks gestation. It is 

typically diagnosed using a two-step process.[81-83] 

• Women with risk factors for GDM (e.g., history of GDM in prior pregnancy, previous delivery of a 

macrosomic infant [>4,000 g], pre-pregnancy BMI >30 kg/m2

, first degree relative with DM, and 

certain high-risk ethnic groups [e.g., Native Americans, Hispanics, Pacific Islanders]) [84] may 

benefit from earlier screening and treatment, but should be re-screened at 24-28 weeks if initial 

testing is normal.

b. Imaging

11. We recommend first-trimester ultrasound to establish or confirm the gestational age and estimated 

birth date, identify multiple pregnancies, and confirm the presence of cardiac activity.

For pregnant women who present after the first trimester, we suggest performing a dating 

and anatomical ultrasound at the earliest opportunity, preferably prior to 22 weeks. (Strong 

for; Reviewed, New-replaced)

• Reliable gestational age is crucial for assessment of fetal size and growth since this may 

influence management decisions that could, in turn, influence outcomes at peri-viable 

gestational ages. Self-report of last menstrual period is often used to estimate gestational age 

but may be unreliable.[85] 

• Ultrasonography before 20 weeks gestation is generally viewed as a more accurate method of 

estimating gestational age than menstrual dating.

c. Preparing for Delivery

12. We recommend offering scheduled delivery to women who reach 41 weeks and 0/7 days 

undelivered. Antepartum fetal testing should begin at 41 weeks and 0/7 days if not scheduled for 

delivery. (Strong for; Not reviewed, Amended)

• Gestational age beyond 40 weeks is associated with increasing risk of perinatal death and 

perinatal complication. Perinatal complications after 41 weeks gestational age have also been 

documented to include asphyxia, fetal distress, sepsis, and meconium aspiration.[86,87] 

• A Cochrane review (2012) identified that a policy of labor induction at 42 weeks gestational age 

compared to expectant management is associated with fewer perinatal deaths and fewer 

cesarean births.[87] There is moderate confidence in the quality of the current evidence that 

women of all ages reduce their negative neonatal outcomes by delivering before 41 and 0/7.[88] 

Studies have also shown an equal or lower rate of cesarean delivery in women for whom 

pregnancy is induced at 41 weeks compared to women for whom expectant management is 

used.[89,90] 

• Counseling women in order to make an informed decision about scheduled inductions or 

antepartum fetal monitoring without induction will help prioritize pregnant women’s values. 

Some women may value immediate delivery, while others may prefer to wait.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 30 of 40

d. Postpartum Care

13. For pregnant women who have a past or current history of gestational diabetes mellitus, 

hypertension, or preeclampsia, we recommend documenting the reproductive history and making 

women aware of the increased lifetime risks of cardiovascular disease and/or diabetes. (Strong for; 

Reviewed, New-added)

• During pregnancy, there are dramatic shifts in blood volume, hemodynamics, and lipid/glucose 

metabolism to accommodate the growing needs of the fetus. However, these adaptive 

mechanisms may become dysregulated and lead to adverse clinical outcomes in both the 

mother and fetus. These adverse conditions that occur during pregnancy can serve as a marker 

of future maternal cardiovascular, metabolic, and possible rheumatologic risk. Such adverse 

conditions include hypertensive conditions of pregnancy, including gestational hypertension and 

preeclampsia, as well as GDM.[91-105] 

• Primary care providers should obtain a reproductive history yearly in women of childbearing 

age; a one-time assessment in women who are postmenopausal without prior history of 

cardiovascular disease (CVD) is sufficient. Specifically, inquiry should be focused on a history of 

gestational hypertension/preeclampsia (previously known as toxemia) and GDM. 

• Benefits of awareness of lifetime risk and regular cardiovascular screening in these women 

outweigh harms.

C. Referral 

14. We suggest that pregnant women with an unexplained elevation of maternal serum alphafetoprotein be evaluated and counseled by a qualified obstetric provider due to increased risk for 

adverse perinatal outcomes. (Weak for; Not reviewed, Amended)

• Studies have indicated an increased risk of adverse outcomes, such as preterm birth, preterm 

rupture of membranes, preeclampsia, fetal growth restriction, and intrauterine fetal death with 

unexplained elevated alpha-fetoprotein.[106-108]

• The benefits of this recommendation slightly outweigh the harms and burdens. The benefit is 

that women with elevated maternal serum alpha-fetoprotein (MSAFP) would undergo 

heightened surveillance and possible earlier detection of preeclampsia or fetal growth 

restriction. They could also be identified as of greater benefit from prophylactic aspirin for 

prevention of preeclampsia. However, there may be a subgroup of women with complications 

that cannot be predicted and knowledge of test results may increase anxiety.

15. We recommend against routine screening for preterm birth using the fetal fibronectin test in 

asymptomatic women. (Strong against; Not reviewed, Amended)

16. We recommend considering the use of fetal fibronectin testing as a part of the evaluation strategy in 

women between 24 and 34 6/7 weeks gestation with signs and symptoms of preterm labor, 

particularly in facilities where the result might affect management of delivery. (Strong for; Not 

reviewed, Amended)

• Fetal fibronectin testing has a narrowly defined role in obstetric evaluation, and therefore should 

only be used when it has the potential to alter care. Several prospective cohort studies have 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 31 of 40

shown no improvement in outcomes for either mother or baby.[109,110] The potential value of 

fetal fibronectin testing in the setting of evaluation or triage of preterm labor is to more precisely 

discriminate between the subset of women who have true preterm labor versus false labor.[111] 

• In a woman at low risk for preterm birth presenting with preterm contractions, a negative test

may inform the decision to use or avoid tocolytics and corticosteroids.[110] Alternatively, a

positive test may allow providers at some facilities to arrange transfer of women identified as at

higher risk of preterm delivery to facilities better suited to manage the complications of a

preterm birth.

• In asymptomatic women, the low positive and negative predictive values limit the test’s value in

medical decision making. Recent studies have found that there is no benefit of fetal fibronectin

testing in asymptomatic women and it is associated with increased use of resources.[112,113]

D. Subpopulations

a. High Risk for Preeclampsia

DI. In women at risk of preeclampsia, we recommend low dose (e.g., 100-150 mg daily) aspirin 

therapy initiated at or before 16 weeks gestation. (Strong for; Reviewed, New-added)

• A systematic review and meta-analysis, including 45 RCTs totaling over 20,000 pregnant women

taking 60-150 mg aspiring daily found that low-dose aspirin therapy initiated at or before 16

weeks gestation, resulted in a significant reduction in preeclampsia, severe preeclampsia, and

fetal growth restriction.[252]

• A dose response effect was observed with higher dosages of aspirin being associated with

greater risk reduction of the three outcomes. In a comparison between 60 mg and 100 mg

aspirin daily, there was no significant impact of 60 mg/day of aspirin on the prevalence of

preeclampsia, severe preeclampsia, or fetal growth restriction. Initiating 100 mg/day of aspirin

before 16 weeks gestation proved to be the most beneficial.[252]

b. High Risk for Preterm Delivery

DII. We recommend antenatal progesterone therapy in consultation with an advanced prenatal care

provider (e.g., maternal fetal medicine provider, perinatologist) for women at high risk for

recurrent preterm delivery and who meet the generally accepted inclusion criteria. (Strong for;

Not reviewed, Amended)

• Studies show that the administration of progesterone intramuscularly or intravaginally

beginning early in pregnancy in women at high risk for preterm birth significantly reduces the

rate of preterm delivery.[114-116] Specifically, women with a prior spontaneous birth at less

than 37 weeks gestation benefit from the administration of progesterone.

• Progesterone therapy is typically started early in the second trimester and continued until

approximately 36 weeks. Both intramuscular 17 alpha-hydroxyprogesterone caproate (250 mg,

administered weekly) and vaginal progesterone suppositories (100-200 mg, administered once

daily) have been found to be effective.[114-116] 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 32 of 40

c. Over 44 Years of Age

19. We suggest offering women greater than 44 years of age planned delivery at 38 weeks gestational

age to reduce the risk of stillbirth. (Weak for; Reviewed, New-added)

• Advanced maternal age has been associated with higher rates of late-term stillbirths.[117]

Compared with women under 35 years of age, women of advanced maternal age appear to

reach late-term stillbirth rates at an earlier gestational age.[118] In addition to the adverse

psychological consequences associated with stillbirth, women of advanced maternal age are

also less likely to become pregnant again.

• One retrospective cohort study of over 16 million pregnancies found that only mothers over the

age of 44 reduced prenatal mortality risk with immediate delivery at 38 weeks gestation. The

relative risk of stillbirth was decreased in women over the age of 44 (relative risk: 0.35, 95%

confidence interval: 0.14-0.90) with planned delivery at 38 weeks compared to expectant

management.[119]

d. History of Bariatric Surgery

20. We suggest that women who have undergone bariatric surgery should be evaluated for nutritional

deficiencies and need for nutritional supplementation where indicated (e.g., vitamin B12, folate,

iron, calcium). (Weak for; Reviewed, New-replaced)

21. For pregnant women who have undergone bariatric surgery, there is insufficient evidence to

recommend for or against the routine supplementation of vitamins A, D, E, or K. (N/A; Reviewed,

New-replaced)

• Although obesity is common and utilization of bariatric surgery has been increasing, there is

very little high quality evidence to support best practices during pregnancy.

• Pregnancies in women after bariatric surgery may need additional care other than routine

prenatal care, as unique risks may be present. Bariatric surgeries may create a risk for nutritional

deficiencies during pregnancy. Thus, patients may be advised to defer pregnancy for at least 18

months after surgery.

• There are minimal risks and potential benefits to evaluation and supplementation for vitamin

B12, folate, iron, and calcium.[120,121]

22. We suggest that pregnant women with a history of gastric bypass surgery be evaluated by a surgeon

with bariatric expertise. (Weak for; Reviewed, Amended)

• Post-bariatric surgery nutritional deficiencies can be avoided with adequate dietary intake but

can be readily addressed and treated when appropriately identified.[122]

• One prospective study found that laparoscopic adjustable gastric banding prior to pregnancy

was safe for both mother and newborn.[123] Another prospective study found that pregnancy

outcomes were similar between obese women who underwent laparoscopic adjustable gastric

banding prior to pregnancy and the general community, rather than those of obese

women.[124] Generally accepted standard of practice for surgeons and dietitians is to follow up

with these patients to monitor for surgical complications as well as nutritional adequacy and any

potential deficiencies associated with the procedure.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 33 of 40

• The Academy of Nutrition and Dietetics (AND) recommends screening for these nutritional risks

and subsequent assessment by an RDN to evaluate the pregnant woman for nutritional

adequacy during this phase of life.[29] In addition to post-bariatric pregnant women, others

with higher risk of nutritional complications include those who are vegetarian or vegan; avoid

certain foods (e.g., due to food allergies, cultural reasons, fad diets); are breastfeeding while

pregnant; are underweight with a BMI <18.5 kg/m2

; are age <17 years old; have a multiple

gestation pregnancy; have a history of hypertension, hyperlipidemia, DM, or GDM; have an

eating disorder; and/or are identified as food insecure.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 34 of 40

References

1. U.S. Department of Veteran Affairs, Department of Defense. Guideline for guidelines. Veterans

Health Administration, Office of Quality & Performance, Evidence Review Subgroup; Revised April

10, 2013.

2. U. S. Preventive Services Task Force. Screening for preeclampsia: U.S. Preventive Services Task

Force recommendation statement. JAMA. 2017;317(16):1661-1667.

3. Triunfo S, Lanzone A. Impact of maternal under nutrition on obstetric outcomes. J Endocrinol

Invest. Jan 2015;38(1):31-38.

4. Katon J, Mattocks K, Zephyrin L, et al. Gestational diabetes and hypertensive disorders of

pregnancy among women veterans deployed in service of operations in Afghanistan and Iraq. J

Womens Health (Larchmt). Oct 2014;23(10):792-800.

5. Centers for Disease Control and Prevention. Weight gain during pregnancy. 2016;

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-weight-gain.htm.

Accessed August 14, 2017.

6. Lynch MM, Amoozegar JB, McClure EM, et al. Improving safe use of medications during

pregnancy: The roles of patients, physicians, and pharmacists. Qualitative Health Research.

2017;27(13):2071-2080.

7. Xiong X, Buekens P, Fraser WD, Beck J, Offenbacher S. Periodontal disease and adverse pregnancy

outcomes: A systematic review. BJOG. Feb 2006;113(2):135-143.

8. Dasanayake AP, Gennaro S, Hendricks-Munoz KD, Chhun N. Maternal periodontal disease,

pregnancy, and neonatal outcomes. MCN Am J Matern Child Nurs. Jan-Feb 2008;33(1):45-49.

9. Michalowicz BS, Hodges JS, DiAngelis AJ, et al. Treatment of periodontal disease and the risk of

preterm birth. N Engl J Med. Nov 02 2006;355(18):1885-1894.

10. Oral health care during pregnancy: A national consensus statement. Washington, DC: National

Maternal and Child Oral Health Resource Center;2012.

11. The use of dental radiographs: Update and recommendations. J Am Dent Assoc. Sep

2006;137(9):1304-1312.

12. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular

pertussis vaccine (Tdap) in pregnant women--Advisory Committee on Immunization Practices

(ACIP), 2012. MMWR Morb Mortal Wkly Rep. Feb 22 2013;62(7):131-135.

13. Englund J, Glezen WP, Piedra PA. Maternal immunization against viral disease. Vaccine. Aug-Sep

1998;16(14-15):1456-1463.

14. Centers for Disease Control and Prevention. Maternal vaccines: Part of a healthy pregnancy. 2016;

https://www.cdc.gov/vaccines/pregnancy/pregnant-women/index.html#vaccines-during.

Accessed June 6, 2017.

15. Smego RA, Jr., Asperilla MO. Use of acyclovir for varicella pneumonia during pregnancy. Obstet

Gynecol. Dec 1991;78(6):1112-1116.

16. Paryani SG, Arvin AM. Intrauterine infection with varicella-zoster virus after maternal varicella. N

Engl J Med. Jun 12 1986;314(24):1542-1546.

17. Brunell PA. Fetal and neonatal varicella-zoster infections. Semin Perinatol. Jan 1983;7(1):47-56.

18. Smith WJ, Jackson LA, Watts DH, Koepsell TD. Prevention of chickenpox in reproductive-age

women: Cost-effectiveness of routine prenatal screening with postpartum vaccination of

susceptibles. Obstet Gynecol. Oct 1998;92(4 Pt 1):535-545.

19. Marin M, Guris D, Chaves SS, Schmid S, Seward JF. Prevention of varicella: Recommendations of

the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. Jun 22

2007;56(RR-4):1-40.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 35 of 40

20. McElhaney RD, Jr., Ringer M, DeHart DJ, Vasilenko P. Rubella immunity in a cohort of pregnant 

women. Infect Control Hosp Epidemiol. Jan 1999;20(1):64-66.

21. Chang TW, DesRosiers S, Weinstein L. Clinical and serologic studies of an outbreak of rubella in a 

vaccinated population. N Engl J Med. Jul 30 1970;283(5):246-248.

22. Horstmann DM, Schluederberg A, Emmons JE, Evans BK, Randolph MF, Andiman WA. Persistence 

of vaccine-induced immune responses to rubella: Comparison with natural infection. Rev Infect 

Dis. Mar-Apr 1985;7 Suppl 1:S80-85.

23. Centers for Disease Control and Prevention. Pregnancy. 

https://www.cdc.gov/pregnancy/index.html. Accessed January 2, 2018.

24. Goh YI, Bollano E, Einarson TR, Koren G. Prenatal multivitamin supplementation and rates of 

pediatric cancers: A meta-analysis. Clin Pharmacol Ther. May 2007;81(5):685-691.

25. Bodnar LM, Tang G, Ness RB, Harger G, Roberts JM. Periconceptional multivitamin use reduces the 

risk of preeclampsia. Am J Epidemiol. Sep 01 2006;164(5):470-477.

26. Operation Supplement Safety. Dietary supplements and women's health. 

https://www.opss.org/articles/dietary-supplements-and-womens-health. Accessed August 15, 

2017.

27. Operation Supplement Safety Should I take dietary supplements while pregnant? 

https://www.opss.org/faqs/should-i-take-dietary-supplements-while-pregnant. Accessed August 

2017, 2017.

28. United States Department of Agriculture. Definitions of food security. 2017; 

https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-offood-security/. Accessed January 2, 2018.

29. Academy of Nutrition and Dietetics. Nutrition care manual products. 2017; 

https://www.nutritioncaremanual.org/?err=NLI. Accessed August 15, 2017.

30. U.S. Preventive Services Task Force. Intimate partner violence and abuse of elderly and vulnerable 

adults: Screening. 2013; 

https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/intimatepartner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening. Accessed June 14, 2014.

31. Iverson KM, King MW, Gerber MR, et al. Accuracy of an intimate partner violence screening tool 

for female VHA patients: A replication and extension. J Trauma Stress. Feb 2015;28(1):79-82.

32. Westin M, Saltvedt S, Bergman G, et al. Routine ultrasound examination at 12 or 18 gestational 

weeks for prenatal detection of major congenital heart malformations? A randomised controlled 

trial comprising 36,299 fetuses. BJOG. Jun 2006;113(6):675-682.

33. Taipale P, Ammala M, Salonen R, Hiilesmaa V. Two-stage ultrasonography in screening for fetal 

anomalies at 13-14 and 18-22 weeks of gestation. Acta Obstet Gynecol Scand. Dec 

2004;83(12):1141-1146.

34. Neilson JP. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev. 

2000(2):CD000182.

35. Mongelli M, Gardosi J. Gestation-adjusted projection of estimated fetal weight. Acta Obstet 

Gynecol Scand. Jan 1996;75(1):28-31.

36. Wilcox M, Gardosi J, Mongelli M, Ray C, Johnson I. Birth weight from pregnancies dated by 

ultrasonography in a multicultural British population. BMJ. Sep 04 1993;307(6904):588-591.

37. Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery. Cochrane Database 

Syst Rev. 2001(1):CD000166.

38. Thorp JM, Jr., Jenkins T, Watson W. Utility of leopold maneuvers in screening for malpresentation. 

Obstet Gynecol. Sep 1991;78(3 Pt 1):394-396.

39. Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane 

Database Syst Rev. 2000(3):CD000051.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 36 of 40

40. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane 

Database Syst Rev. 2000(2):CD000083.

41. The guidelines manual. London: National Institute for Health and Care Excellence;2012. 

http://www.nice.org.uk/article/pmg6/resources/non-guidance-the-guidelines-manual-pdf.

42. Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated 

recommendations: An assessment of NICE clinical guidelines. Implement Sci. 2014;9:72.

43. Bertakis KD, Azari R. Patient-centered care is associated with decreased health care utilization. J 

Am Board Fam Med. May-Jun 2011;24(3):229-239.

44. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: Definitions 

and applications to improve outcomes. J Am Acad Nurse Pract. Dec 2008;20(12):600-607.

45. Crossing the quality chasm: A new health system for the 21st century. Washington DC: National 

Academies Press;2001.

46. Carter EB, Temming LA, Akin J, et al. Group prenatal care compared with traditional prenatal care: 

A systematic review and meta-analysis. Obstet Gynecol. Sep 2016;128(3):551-561.

47. Ickovics JR, Kershaw TS, Westdahl C, et al. Group prenatal care and perinatal outcomes: A 

randomized controlled trial. Obstet Gynecol. Aug 2007;110(2 Pt 1):330-339.

48. Di Mascio D, Magro-Malosso ER, Saccone G, Marhefka GD, Berghella V. Exercise during pregnancy 

in normal-weight women and risk of preterm birth: A systematic review and meta-analysis of 

randomized controlled trials. Am J Obstet Gynecol. Nov 2016;215(5):561-571.

49. Aune D, Sen A, Henriksen T, Saugstad OD, Tonstad S. Physical activity and the risk of gestational 

diabetes mellitus: A systematic review and dose-response meta-analysis of epidemiological 

studies. Eur J Epidemiol. Oct 2016;31(10):967-997.

50. Magro-Malosso ER, Saccone G, Di Mascio D, Di Tommaso M, Berghella V. Exercise during 

pregnancy and risk of preterm birth in overweight and obese women: A systematic review and 

meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand. Mar 2017;96(3):263-

273.

51. Harrison AL, Shields N, Taylor NF, Frawley HC. Exercise improves glycaemic control in women 

diagnosed with gestational diabetes mellitus: A systematic review. J Physiother. Oct 

2016;62(4):188-196.

52. Wiebe HW, Boule NG, Chari R, Davenport MH. The effect of supervised prenatal exercise on fetal 

growth: A meta-analysis. Obstet Gynecol. May 2015;125(5):1185-1194.

53. Elliott-Sale KJ, Barnett CT, Sale C. Exercise interventions for weight management during pregnancy 

and up to 1 year postpartum among normal weight, overweight and obese women: A systematic 

review and meta-analysis. Br J Sports Med. Oct 2015;49(20):1336-1342.

54. Gong H, Ni C, Shen X, Wu T, Jiang C. Yoga for prenatal depression: A systematic review and metaanalysis. BMC Psychiatry. Feb 05 2015;15:14.

55. Muktabhant B, Lawrie TA, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing 

excessive weight gain in pregnancy. Cochrane Database Syst Rev. Jun 15 2015(6):CD007145.

56. Centers for Disease Control and Prevention. Perceived exertion (Borg Rating of Perceived Exertion 

Scale). 2015; https://www.cdc.gov/physicalactivity/basics/measuring/exertion.htm. Accessed June 

6, 2017.

57. Gabbe SG, Turner LP. Reproductive hazards of the American lifestyle: Work during pregnancy. Am 

J Obstet Gynecol. Apr 1997;176(4):826-832.

58. Teitelman AM, Welch LS, Hellenbrand KG, Bracken MB. Effect of maternal work activity on 

preterm birth and low birth weight. Am J Epidemiol. Jan 1990;131(1):104-113.

59. Mozurkewich EL, Luke B, Avni M, Wolf FM. Working conditions and adverse pregnancy outcome: A 

meta-analysis. Obstet Gynecol. Apr 2000;95(4):623-635.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 37 of 40

60. Luke B, Mamelle N, Keith L, et al. The association between occupational factors and preterm birth: 

A United States nurses' study. Research Committee of the Association of Women's Health, 

Obstetric, and Neonatal Nurses. Am J Obstet Gynecol. Sep 1995;173(3 Pt 1):849-862.

61. Werler MM, Hayes C, Louik C, Shapiro S, Mitchell AA. Multivitamin supplementation and risk of 

birth defects. Am J Epidemiol. Oct 01 1999;150(7):675-682.

62. Lumley J, Watson L, Watson M, Bower C. Periconceptional supplementation with folate and/or 

multivitamins for preventing neural tube defects. Cochrane Database Syst Rev. 2001(3):CD001056.

63. De-Regil LM, Pena-Rosas JP, Fernandez-Gaxiola AC, Rayco-Solon P. Effects and safety of 

periconceptional oral folate supplementation for preventing birth defects. Cochrane Database Syst 

Rev. Dec 14 2015(12):CD007950.

64. Folic acid for the prevention of neural tube defects: U.S. Preventive Services Task Force 

recommendation statement. Ann Intern Med. May 05 2009;150(9):626-631.

65. Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Folic acid supplementation for the prevention of 

neural tube defects: US Preventive Services Task Force recommendation statement. JAMA. Jan 10 

2017;317(2):183-189.

66. Viteri OA, Soto EE, Bahado-Singh RO, Christensen CW, Chauhan SP, Sibai BM. Fetal anomalies and 

long-term effects associated with substance abuse in pregnancy: A literature review. Am J 

Perinatol. Apr 2015;32(5):405-416.

67. Caputo C, Wood E, Jabbour L. Impact of fetal alcohol exposure on body systems: A systematic 

review. Birth Defects Res C Embryo Today. Jun 2016;108(2):174-180.

68. Tolia VN, Patrick SW, Bennett MM, et al. Increasing incidence of the neonatal abstinence 

syndrome in U.S. neonatal ICUs. New England Journal of Medicine. 2015;372(22):2118-2126.

69. O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and 

treatment of depression in pregnant and postpartum women: Evidence report and systematic 

review for the US Preventive Services Task Force. JAMA. Jan 26 2016;315(4):388-406.

70. World Health Organization. Breastfeeding. 2018; http://www.who.int/topics/breastfeeding/en/. 

Accessed January 2, 2018.

71. Centers for Disease Control and Prevention. Breastfeeding. 2017; 

https://www.cdc.gov/breastfeeding/index.htm. Accessed September 21, 2017.

72. Office on Women's Health, U.S. Department of Health and Human Services. Breastfeeding. 2017; 

https://www.womenshealth.gov/breastfeeding/. Accessed December 22, 2017.

73. Chard RL, Norton ME. Genetic counseling for patients considering screening and diagnosis for 

chromosomal abnormalities. Clin Lab Med. Jun 2016;36(2):227-236.

74. Gil MM, Quezada MS, Revello R, Akolekar R, Nicolaides KH. Analysis of cell-free DNA in maternal 

blood in screening for fetal aneuploidies: Updated meta-analysis. Ultrasound Obstet Gynecol. Mar 

2015;45(3):249-266.

75. Mackie FL, Hemming K, Allen S, Morris RK, Kilby MD. The accuracy of cell-free fetal DNA-based 

non-invasive prenatal testing in singleton pregnancies: A systematic review and bivariate metaanalysis. BJOG. Jan 2017;124(1):32-46.

76. Oepkes D, Page-Christiaens GC, Bax CJ, et al. Trial by Dutch laboratories for evaluation of noninvasive prenatal testing. Part I-clinical impact. Prenat Diagn. Dec 2016;36(12):1083-1090.

77. Norton ME, Baer RJ, Wapner RJ, Kuppermann M, Jelliffe-Pawlowski LL, Currier RJ. Cell-free DNA vs 

sequential screening for the detection of fetal chromosomal abnormalities. Am J Obstet Gynecol. 

Jun 2016;214(6):727 e721-726.

78. Stokowski R, Wang E, White K, et al. Clinical performance of non-invasive prenatal testing (NIPT) 

using targeted cell-free DNA analysis in maternal plasma with microarrays or next generation 

sequencing (NGS) is consistent across multiple controlled clinical studies. Prenat Diagn. Dec 

2015;35(12):1243-1246.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 38 of 40

79. Johansen P, Richter SR, Balslev-Harder M, et al. Open source non-invasive prenatal testing 

platform and its performance in a public health laboratory. Prenat Diagn. Jun 2016;36(6):530-536.

80. Berggren EK, Boggess KA, Mathew L, Culhane J. First trimester maternal glycated hemoglobin and 

sex hormone-binding globulin do not predict third trimester glucose intolerance of pregnancy. 

Reprod Sci. Apr 2017;24(4):613-618.

81. Danilenko-Dixon DR, Van Winter JT, Nelson RL, Ogburn PL, Jr. Universal versus selective gestational 

diabetes screening: Application of 1997 American Diabetes Association recommendations. Am J 

Obstet Gynecol. Oct 1999;181(4):798-802.

82. Griffin ME, Coffey M, Johnson H, et al. Universal vs. Risk factor-based screening for gestational 

diabetes mellitus: Detection rates, gestation at diagnosis and outcome. Diabet Med. Jan 

2000;17(1):26-32.

83. Williams CB, Iqbal S, Zawacki CM, Yu D, Brown MB, Herman WH. Effect of selective screening for

gestational diabetes. Diabetes Care. Mar 1999;22(3):418-421.

84. Solomon CG, Willett WC, Carey VJ, et al. A prospective study of pregravid determinants of 

gestational diabetes mellitus. JAMA. Oct 01 1997;278(13):1078-1083.

85. Hoffman CS, Messer LC, Mendola P, Savitz DA, Herring AH, Hartmann KE. Comparison of 

gestational age at birth based on last menstrual period and ultrasound during the first trimester. 

Paediatr Perinat Epidemiol. Nov 2008;22(6):587-596.

86. Olesen AW, Westergaard JG, Olsen J. Perinatal and maternal complications related to postterm 

delivery: A national register-based study, 1978-1993. Am J Obstet Gynecol. Jul 2003;189(1):222-

227.

87. Gülmezoglu AM, Crowther CA, Middleton P, Heatley E. Induction of labour for improving birth 

outcomes for women at or beyond term. The Cochrane database of systematic reviews. 06/13 

2012;6:CD004945-CD004945.

88. Zizzo AR, Kirkegaard I, Pinborg A, Ulbjerg N. Decline in stillbirths and perinatal mortality after 

implementation of a more aggressive induction policy in post-date pregnancies: A nationwide 

register study. Acta Obstet Gynecol Scand. Feb 10 2017.

89. Heimstad R, Romundstad PR, Salvesen KA. Induction of labour for post-term pregnancy and risk 

estimates for intrauterine and perinatal death. Acta Obstet Gynecol Scand. 2008;87(2):247-249.

90. Sanchez-Ramos L, Olivier F, Delke I, Kaunitz AM. Labor induction versus expectant management 

for postterm pregnancies: A systematic review with meta-analysis. Obstet Gynecol. Jun 

2003;101(6):1312-1318.

91. Wu P, Haththotuwa R, Kwok CS, et al. Preeclampsia and future cardiovascular health: A systematic 

review and meta-analysis. Circ Cardiovasc Qual Outcomes. Feb 2017;10(2).

92. Brown MC, Best KE, Pearce MS, Waugh J, Robson SC, Bell R. Cardiovascular disease risk in women

with pre-eclampsia: Systematic review and meta-analysis. Eur J Epidemiol. Jan 2013;28(1):1-19.

93. Wang Z, Wang Z, Wang L, et al. Hypertensive disorders during pregnancy and risk of type 2 

diabetes in later life: A systematic review and meta-analysis. Endocrine. Mar 2017;55(3):809-821.

94. Fadl H, Magnuson A, Ostlund I, Montgomery S, Hanson U, Schwarcz E. Gestational diabetes 

mellitus and later cardiovascular disease: A Swedish population based case-control study. BJOG. 

Nov 2014;121(12):1530-1536.

95. Gunderson EP, Chiang V, Pletcher MJ, et al. History of gestational diabetes mellitus and future risk 

of atherosclerosis in mid-life: The coronary artery risk development in young adults study. J Am 

Heart Assoc. Mar 12 2014;3(2):e000490.

96. Kessous R, Shoham-Vardi I, Pariente G, Sherf M, Sheiner E. An association between gestational 

diabetes mellitus and long-term maternal cardiovascular morbidity. Heart. Aug 2013;99(15):1118-

1121.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 39 of 40

97. Retnakaran R, Shah BR. Mild glucose intolerance in pregnancy and risk of cardiovascular disease: A 

population-based cohort study. CMAJ. Sep 15 2009;181(6-7):371-376.

98. Cirillo PM, Cohn BA. Pregnancy complications and cardiovascular disease death: 50-year follow-up 

of the child health and development studies pregnancy cohort. Circulation. Sep 29 

2015;132(13):1234-1242.

99. Fraser A, Nelson SM, Macdonald-Wallis C, et al. Associations of pregnancy complications with 

calculated cardiovascular disease risk and cardiovascular risk factors in middle age: The Avon 

Longitudinal Study of Parents and Children. Circulation. Mar 20 2012;125(11):1367-1380.

100. Jorgensen KT, Pedersen BV, Jacobsen S, Biggar RJ, Frisch M. National cohort study of reproductive 

risk factors for rheumatoid arthritis in Denmark: A role for hyperemesis, gestational hypertension 

and pre-eclampsia? Ann Rheum Dis. Feb 2010;69(2):358-363.

101. Wahlberg J, Ekman B, Nystrom L, Hanson U, Persson B, Arnqvist HJ. Gestational diabetes: 

Glycaemic predictors for fetal macrosomia and maternal risk of future diabetes. Diabetes Res Clin 

Pract. Apr 2016;114:99-105.

102. Waldman M, Sheiner E, Sergienko R, Shoham-Vardi I. Can we identify risk factors during pregnancy 

for thrombo-embolic events during the puerperium and later in life? J Matern Fetal Neonatal Med. 

Jun 2015;28(9):1005-1009.

103. Auger N, Fraser WD, Paradis G, Healy-Profitos J, Hsieh A, Rheaume MA. Preeclampsia and longterm risk of maternal retinal disorders. Obstet Gynecol. Jan 2017;129(1):42-49.

104. Auger N, Fraser WD, Schnitzer M, Leduc L, Healy-Profitos J, Paradis G. Recurrent pre-eclampsia and 

subsequent cardiovascular risk. Heart. Feb 2017;103(3):235-243.

105. Drost JT, Arpaci G, Ottervanger JP, et al. Cardiovascular risk factors in women 10 years post early 

preeclampsia: The Preeclampsia Risk EValuation in FEMales study (PREVFEM). Eur J Prev Cardiol. 

Oct 2012;19(5):1138-1144.

106. Dugoff L, Hobbins JC, Malone FD, et al. Quad screen as a predictor of adverse pregnancy outcome. 

Obstet Gynecol. Aug 2005;106(2):260-267.

107. Summers AM, Langlois S, Wyatt P, Wilson RD. Prenatal screening for fetal aneuploidy. J Obstet 

Gynaecol Can. Feb 2007;29(2):146-179.

108. ACOG Practice Bulletin No. 77: Screening for fetal chromosomal abnormalities. Obstet Gynecol. Jan 

2007;109(1):217-227.

109. Leitich H, Egarter C, Kaider A, Hohlagschwandtner M, Berghammer P, Husslein P. Cervicovaginal 

fetal fibronectin as a marker for preterm delivery: A meta-analysis. Am J Obstet Gynecol. May 

1999;180(5):1169-1176.

110. Ramsey PS, Andrews WW. Biochemical predictors of preterm labor: Fetal fibronectin and salivary 

estriol. Clin Perinatol. Dec 2003;30(4):701-733.

111. Honest H, Bachmann LM, Gupta JK, Kleijnen J, Khan KS. Accuracy of cervicovaginal fetal fibronectin 

test in predicting risk of spontaneous preterm birth: Systematic review. BMJ. Aug 10 

2002;325(7359):301.

112. Berghella V, Saccone G. Fetal fibronectin testing for prevention of preterm birth in singleton 

pregnancies with threatened preterm labor: A systematic review and metaanalysis of randomized 

controlled trials. Am J Obstet Gynecol. Oct 2016;215(4):431-438.

113. Esplin MS, Elovitz MA, Iams JD, et al. Predictive accuracy of serial transvaginal cervical lengths and 

quantitative vaginal fetal fibronectin levels for spontaneous preterm birth among nulliparous 

women. JAMA. Mar 14 2017;317(10):1047-1056.

114. da Fonseca EB, Bittar RE, Carvalho MH, Zugaib M. Prophylactic administration of progesterone by 

vaginal suppository to reduce the incidence of spontaneous preterm birth in women at increased 

risk: A randomized placebo-controlled double-blind study. Am J Obstet Gynecol. Feb 

2003;188(2):419-424.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy – Clinician Summary

March 2018 Page 40 of 40

115. Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH. Progesterone and the risk of preterm birth 

among women with a short cervix. New England Journal of Medicine. 2007;357(5):462-469.

116. Meis PJ, Klebanoff M, Thom E, et al. Prevention of recurrent preterm delivery by 17 alphahydroxyprogesterone caproate. New England Journal of Medicine. 2003;348(24):2379-2385.

117. Smith GC. Life-table analysis of the risk of perinatal death at term and post term in singleton 

pregnancies. Am J Obstet Gynecol. Feb 2001;184(3):489-496.

118. Barton JR, Sibai AJ, Istwan NB, Rhea DJ, Desch CN, Sibai BM. Spontaneously conceived pregnancy 

after 40: Influence of age and obesity on outcome. Am J Perinatol. Oct 2014;31(9):795-798.

119. Chaudhary S, Contag S. The effect of maternal age on fetal and neonatal mortality. J Perinatol. Mar 

30 2017.

120. Devlieger R, Guelinckx I, Jans G, Voets W, Vanholsbeke C, Vansant G. Micronutrient levels and 

supplement intake in pregnancy after bariatric surgery: A prospective cohort study. PLoS One. 

2014;9(12):e114192.

121. Jans G, Guelinckx I, Voets W, et al. Vitamin K1 monitoring in pregnancies after bariatric surgery: A 

prospective cohort study. Surg Obes Relat Dis. Sep-Oct 2014;10(5):885-890.

122. Wax JR, Pinette MG, Cartin A, Blackstone J. Female reproductive issues following bariatric surgery. 

Obstet Gynecol Surv. Sep 2007;62(9):595-604.

123. Bar-Zohar D, Azem F, Klausner J, Abu-Abeid S. Pregnancy after laparoscopic adjustable gastric 

banding: Perinatal outcome is favorable also for women with relatively high gestational weight 

gain. Surg Endosc. Oct 2006;20(10):1580-1583.

124. Dixon JB, Dixon ME, O'Brien PE. Birth outcomes in obese women after laparoscopic adjustable 

gastric banding. Obstet Gynecol. Nov 2005;106(5 Pt 1):965-972.