March 2018 Page 1 of 10

VA/DoD CLINICAL PRACTICE GUIDELINE FOR 

MANAGEMENT OF PREGNANCY

Department of Veterans Affairs

Department of Defense

Pocket Card

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
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I. Summary of Recommendations

Recommendations were made using a systematic approach considering multiple domains: the confidence 

in the quality of the evidence, balance of desirable and undesirable outcomes, patient or provider values 

and preferences, and other implications, as appropriate (e.g., resource use, equity, acceptability).

A. Care Throughout Pregnancy

We recommend:

• Mild to moderate exercise sessions three or more times per week for those without known

contraindications

• Folic acid (at least 400 micrograms daily) starting one month before conception and continued

throughout pregnancy and breastfeeding

• Screening for use of tobacco, alcohol, illicit drugs, and unauthorized use of prescription

medication with additional evaluation and treatment based on results (see VA/DoD Clinical

Practice Guidelines for the Management of Substance Use Disorders1 and the Management of

Tobacco Use2

)

• Screening for depression using a standardized tool (e.g., Edinburgh Postnatal Depression Scale,

9-item Patient Health Questionnaire) periodically during pregnancy and postpartum

• Breastfeeding education, assessment, and support at the first visit and throughout pregnancy

and the postpartum period using open-ended questions such as “What do you know about

breastfeeding?”

We suggest:

• Offering a group model of prenatal care as an alternative to individual provider appointments

• For women with uncomplicated pregnancies, continuation of a standard work schedule

throughout pregnancy

B. One-time Interventions

We recommend:

• Offering prenatal screening for aneuploidy and most common clinically significant genetic

disorders

 When aneuploidy screening is desired, consider cell-free fetal DNA screening; however, 

test selection should be individualized and take into account the patient’s age, baseline 

aneuploidy risk, and test performance for a given condition

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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• First-trimester ultrasound to establish or confirm gestational age and estimated birth date,

identify multiple pregnancies, and confirm the presence of cardiac activity

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

anatomical ultrasound at the earliest opportunity, preferably prior to 22 weeks

• Offering scheduled delivery to women who reach 41 and 0/7 days undelivered; start

antepartum fetal testing at 41 weeks and 0/7 days if not scheduled for delivery

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

hypertension, or preeclampsia, documenting reproductive history and making women aware of

increased lifetime risks of cardiovascular disease and/or diabetes

We suggest:

• Making prenatal diagnostic testing for aneuploidy available to all pregnant women

• 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

C. Referral

We recommend:

• Considering 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

We suggest:

• Evaluation and counseling by a qualified obstetric provider for pregnant women with an

unexplained elevation of maternal serum alpha-fetoprotein

We recommend against:

• Routine screening for preterm delivery using the fetal fibronectin test in asymptomatic women

D. Subpopulations

We recommend:

• For women at risk of preeclampsia, low dose (e.g., 100-150 mg daily) aspirin therapy initiated at

or before 16 weeks gestation

• For women at high risk for recurrent preterm delivery and who meet the generally accepted

inclusion criteria, antenatal progesterone therapy in consultation with an advanced prenatal

care provider

We suggest:

• For women greater than 44 years of age, offering planned delivery at 38 weeks gestation to

reduce the risk of stillbirth
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• For women who have undergone bariatric surgery, evaluation for nutritional deficiencies and

need for nutritional supplementation

• For women with a history of gastric bypass surgery, evaluation by a surgeon with bariatric

expertise

There is inconclusive evidence to recommend for or against:

• For women who have undergone bariatric surgery, routine supplementation of vitamins A, D, E,

or K
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II. Algorithm

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

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 section below on Routine Pregnancy Care and the section in the full CPG on 

Standard of Pregnancy Care. The recommendation numbering refers to each recommendation 

as it is listed in the full CPG. Please see the full CPG for the complete list of recommendations 

and accompanying discussions.

C. Interventions by Weeks Gestation
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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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III. 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 1. Consideration of antepartum referrals to advanced prenatal care providers 

can be informed by Table 2. 

Table 1. 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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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
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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; 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

Table 2. 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)

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

Intrauterine fetal demise