VA/DOD CLINICAL PRACTICE GUIDELINE FOR 

THE MANAGEMENT OF PREGNANCY

Department of Veterans Affairs

Department of Defense

QUALIFYING STATEMENTS

The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best 

information available at the time of publication. They are designed to provide information and assist 

decision making. They are not intended to define a standard of care and should not be construed as one.

Neither should they be interpreted as prescribing an exclusive course of management. 

This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological 

evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical 

relationships between various care options and health outcomes while rating both the quality of the 

evidence and the strength of the recommendation. 

Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of 

individual patients, available resources, and limitations unique to an institution or type of practice. Every 

healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of 

applying them in the setting of any particular clinical situation.

These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy. 

Further, inclusion of recommendations for specific testing and/or therapeutic interventions within these 

guidelines does not guarantee coverage of civilian sector care. Additional information on current 

TRICARE benefits may be found at www.tricare.mil or by contacting your regional TRICARE Managed 

Care Support Contractor. 

Version 3.0 – 2018
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

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Prepared by:

The Management of Pregnancy Work Group

With support from:

The Office of Quality, Safety and Value, VA, Washington, DC

& 

Office of Evidence Based Practice, U.S. Army Medical Command

Version 3.0 – 2018 

Based on evidence reviewed through May 2017
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Table of Contents

I. Introduction..................................................................................................................................... 6

II. Background...................................................................................................................................... 6

A. Description of Pregnancy .................................................................................................................... 6

B. Epidemiology and Impact in the General Population ........................................................................ 7

a. Rates of Reproduction ................................................................................................................. 7

b. Pregnancy Complications............................................................................................................ 7

C. Pregnancy in the Department of Defense and the Department of Veterans Affairs Populations... 8

a. Location of Care........................................................................................................................... 8

b. Rates of Reproduction ................................................................................................................. 9

c. Complications .............................................................................................................................. 9

III. About this Clinical Practice Guideline ............................................................................................. 10

A. Methods.............................................................................................................................................10

a. Grading Recommendations.......................................................................................................11

b. Reconciling 2009 Clinical Practice Guideline Recommendations.............................................13

c. Peer Review Process..................................................................................................................14

B. Summary of Patient Focus Group Methods and Findings................................................................14

C. Conflicts of Interest ...........................................................................................................................15

D. Scope of this Clinical Practice Guideline ...........................................................................................16

E. Highlighted Features of this Clinical Practice Guideline...................................................................16

F. Patient-centered Care .......................................................................................................................16

G. Shared Decision Making ....................................................................................................................17

H. Co-occurring Conditions....................................................................................................................17

I. Implementation................................................................................................................................. 18

IV. Guideline Work Group ................................................................................................................... 19

V. Algorithm ...................................................................................................................................... 20

A. Algorithm Key ....................................................................................................................................21

B. Actions at Every Visit .........................................................................................................................21

C. Interventions by Weeks Gestation....................................................................................................21

D. Standard of Pregnancy Care..............................................................................................................23

a. Additional Information on Actions at Every Visit......................................................................23

b. Screenings..................................................................................................................................24

c. Time Sensitive Care....................................................................................................................28

d. Summary....................................................................................................................................28
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VI. Routine Pregnancy Care................................................................................................................. 29

VII. Recommendations......................................................................................................................... 33

A. Care Throughout Pregnancy..............................................................................................................36

a. Routine Care During Pregnancy ................................................................................................36

b. Nutrition.....................................................................................................................................39

c. Screening....................................................................................................................................40

d. Education ...................................................................................................................................43

B. One-time Interventions.....................................................................................................................44

a. Screening and Diagnostic Testing .............................................................................................44

b. Imaging ......................................................................................................................................49

c. Preparing for Delivery................................................................................................................50

d. Postpartum Care........................................................................................................................51

C. Referral...............................................................................................................................................52

D. Special Considerations.......................................................................................................................55

a. High Risk for Preeclampsia........................................................................................................55

b. High Risk for Preterm Delivery ..................................................................................................56

c. Over 44 Years of Age .................................................................................................................57

d. History of Bariatric Surgery .......................................................................................................58

Appendix A: Evidence Review Methodology....................................................................................... 62

A. Developing the Scope and Key Questions........................................................................................62

a. Population(s)..............................................................................................................................62

b. Interventions..............................................................................................................................62

c. Comparators..............................................................................................................................64

d. Outcomes...................................................................................................................................65

B. Conducting the Systematic Review...................................................................................................67

a. General Criteria for Inclusion in Systematic Review................................................................. 69

b. Key Question Specific Criteria....................................................................................................70

c. Literature Search Strategy.........................................................................................................71

C. Convening the Face-to-face Meeting................................................................................................71

D. Grading Recommendations...............................................................................................................72

E. Recommendation Categorization .....................................................................................................75

a. Recommendation Categories and Definitions..........................................................................75

b. Categorizing Recommendations with an Updated Review of the Evidence............................76

c. Categorizing Recommendations without an Updated Review of the Evidence ......................77

F. Drafting and Submitting the Final Clinical Practice Guideline..........................................................77

Appendix B: Patient Focus Group Methods and Findings.................................................................... 79
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A. Methods.............................................................................................................................................79

B. Patient Focus Group Findings............................................................................................................79

Appendix C: Evidence Table ............................................................................................................... 82

Appendix D: 2009 Recommendation Categorization Table.................................................................. 86

Appendix E: Participant List.............................................................................................................. 107

Appendix F: Literature Review Search Terms and Strategy ............................................................... 109

A. Topic-specific Search Terms............................................................................................................109 

B. Search Strategies .............................................................................................................................119

Appendix G: Abbreviation List .......................................................................................................... 133

References .......................................................................................................................................... 135
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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)

II. Background

A. Description of Pregnancy

Pregnancy is the reproductive time during which a developing fetus grows inside of the uterus. It is a time 

of dramatic change for a developing fetus and a woman’s body. Most pregnancies are uncomplicated and 

labor results in a normal vaginal birth with a healthy mother and baby. Rarely, complications arise, which 

have the potential to lead to lifelong implications. As the fetus continues to develop throughout the course 

of the pregnancy, the gestational age at birth can help predict outcomes (Table 1).[ ] 2-4

While pregnancy and birth are normal physiological events, pregnancy is a period of increased risk for a 

range of conditions. It is also a time of great interaction with the healthcare system, affording an 

opportunity to optimally manage chronic health conditions and provide preventative care. The healthcare 

team’s goal is to maintain or improve the mother’s health to foster normal and healthy development of 

the baby, culminating in a full-term birth. The physical, psychological, and social support that the mother 

receives during her pregnancy can help reduce health problems in her and the child’s life. Evidence-based 

care during pregnancy can have a life-long impact on both mother and baby. 
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Table 1. Gestational Age at Birth Predicts Offspring Outcomes [ ] 2-5

Term

Gestational Age at 

Birth Outcomes

Preterm <37 weeks Increased risk for adverse outcomes such as respiratory, gastrointestinal, 

and neurologic 

Late 

preterm 

34 0/7 - 36 6/7 weeks Decreased risk for adverse outcomes compared to other preterm infants, 

but increased risk for adverse outcomes compared to term infants 

Early-term 37 0/7 - 38 6/7 weeks Increased risk of adverse outcomes, particularly respiratory, compared to 

full-term infants 

Full-term 39 0/7 - 40 6/7 weeks Fully developed lungs, brains, and livers; have better health outcomes 

than infants born outside of this time period

Late-term 41 0/7 -41 6/7 weeks Increased risk of adverse neonatal outcomes compared to full-term 

infants 

Post-term >41 6/7 weeks Increased risk of adverse neonatal outcomes compared to full-term 

infants

B. Epidemiology and Impact in the General Population

a. Rates of Reproduction

In 2014, there were 3,978,497 registered births in the United States (U.S.).[ ] In general, between 1990 

and 2014, rates of reproduction in the U.S. have decreased.[ ] Women have also been giving birth at later 

ages. Mean age at first delivery increased from 24.9 years in 2000 to 26.3 years in 2014. Changes were 

most pronounced between 2009 and 2014.[ ] There are many possible drivers for the decrease in rates of 

reproduction in the past few decades and the increasing number of deliveries later in women’s lives, such 

as women’s increasing prioritization on education and establishing careers prior to having children and 

improved access to contraception and reproductive health services. 

6

7

8

b. Pregnancy Complications

Although there have been advances in medicine and medical technologies over the past 25 years, 

maternal pregnancy-related mortality and morbidity have been increasing. Common complications that 

can occur during pregnancy include maternal obesity or excessive weight gain, mental health conditions 

(e.g., depression, anxiety, posttraumatic stress disorder [PTSD]), hyperemesis gravidarum, anemia, 

gestational diabetes mellitus (GDM), and hypertensive disorders of pregnancy (e.g., gestational 

hypertension, preeclampsia, eclampsia).[ ] 9

Pregnancy-related deaths (approximately 600 each year) occur due to reasons such as heart conditions, 

infections, bleeding, blood clots, and high blood pressure triggered or exacerbated by pregnancy. Severe 

maternal morbidity affects approximately 65,000 women in the U.S. each year. The risk of morbidity 

doubled between 2000 and 2010 which is likely related to a number of factors, such as increased maternal 

age, pre-pregnancy obesity, preexisting chronic conditions, and an increasing number of cesarean 

deliveries.[ ] 10

Some complications that arise during pregnancy, such as ectopic pregnancy, may require immediate 

attention while others are more chronic. Regardless of the type of complication, each requires the 

appropriate level of medical support, which may vary depending on the pregnant woman’s current 

environment. Once a woman has delivered her baby, she may struggle with breastfeeding in the context of 
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unpredictable and demanding work schedules. Federal laws addressing breastfeeding in the workplace 

exist but are relatively new.[ ] 11

In contrast, the infant mortality rate has declined 15% between 2005 and 2015, from 6.86 infant deaths

per 1,000 live births to 5.82.[ ] The Centers for Disease Control and Prevention (CDC) indicated the 

following were the five leading causes of infant death in 2014:[ ] 

12

13

• Birth defects

• Preterm birth or low birth weight

• Maternal complications of pregnancy

• Sudden infant death syndrome (SIDS)

• Unintentional injuries (e.g., accidental suffocation)

From 2005 to 2014, congenital malformations remained the leading cause of infant death, although 

congenital malformations declined by 11% during that period. Preterm birth rates rose over 20% from 

1990 (10.6%) through 2006 (12.8%). The preterm birth rate then declined from 2007 through 2014 from 

10.4% to 9.6%, but increased slightly to 9.6% in 2015. Increases in preterm births were seen among nonHispanic black and Hispanic women.[14] 

Cesarean birth may be planned for breech presentation, prior uterine surgery, or as a response to 

unexpected maternal or fetal complications such as abnormal labor or a concerning fetal heart rate.[ ] 

Cesarean delivery is a major surgery with associated risks (e.g., risk of infection, hemorrhage). Cesarean 

delivery requires a longer period for maternal recovery than vaginal birth and has also been associated 

with neonatal complications, primarily respiratory.[ ] There has been a downward trend in cesarean 

births between 2009 (32.9%) and 2015 (32.0%). The rate of low-risk cesarean births (defined as 

nulliparous, term, singleton, vertex cesarean deliveries to women having a first delivery) also declined 

from 2009 (28.0%) to 2015 (25.8%).[ ] 

15

15

16

C. Pregnancy in the Department of Defense and the Department of Veterans 

Affairs Populations

a. Location of Care

This VA/DoD Pregnancy CPG is relevant to providers within the DoD and VA healthcare systems as well as 

in the broader community due to the way in which pregnancy care is provided through these systems. 

Pregnant Service Members and their dependent spouses can receive their pregnancy care through the 

DoD healthcare system or civilian providers within the community. As VA does not provide routine 

prenatal or pregnancy care on-site, pregnancy care is provided in the community via referral. Each VA 

medical center has a maternity care coordinator who fosters communication between the pregnant 

woman, non-VA providers, and the VA facility and who is responsible for monitoring care delivery, 

coordinating care, and tracking outcomes of VA-funded services. 

Due to the nature of the provision of pregnancy care, ongoing care coordination and communication 

between VA/DoD providers and any community obstetric providers is necessary to ensure that each 

Service Member and Veteran is receiving the care she needs and that all providers are fully aware of 
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information relevant to the pregnant woman’s health and treatment plan. More information on this is 

available in the section on Patient Focus Group Methods and Findings. 

b. Rates of Reproduction

Between 2003 and 2014, 174,921 infants were born to Active Duty Service Members.[ ] Recently, from 

2012-2016, annual prevalence of pregnancy-related events has decreased from 14.2% to 13.1%. The birth 

rate has also decreased from 69.8 live births per 1,000 person-years in 2012 to 59.7 live births per 1,000 

person-years in 2016.[ ] Between 2003 and 2014, 1,043,812 infants were born to dependent spouses of 

Active Duty Service Members.[ ] 

17

18

17

Between fiscal years 2000 and 2010, the VA covered an estimated total of 12,000 inpatient deliveries 

through community providers. Over this time period, the number of deliveries covered by the VA has 

increased from approximately 350 per year in 2000 to more than 2,000 per year in 2010.[ ] As the 

female, childbearing-age Veteran population increases, use of maternity and newborn care may also 

increase. 

19

c. Complications

Although women Service Members and Veterans experience some of the same challenges during 

pregnancy as women in the general population, they also may have different challenges and pregnancy 

care needs than their civilian counterparts. Their service experience may have included involvement in 

combat or environmental/occupational exposures (e.g., fumes from burn pits, chemical toxicants). Servicerelated stressors such as those present in the lives of Service Members and Veterans may amplify the 

physical and psychological stresses of pregnancy. Although there is limited information regarding the 

impact of such exposures on reproductive health outcomes, the effort to assess the possible health 

impacts of military experience on women and their implications for obstetric healthcare is ongoing.[ ] 19

As in the general population, in some cases, births in Veterans and Service Members are affected by 

complications. The following data relates to complications experienced in pregnancies of Active Duty 

Service Members, which appear to be similar to those of the dependent spouses of Active Duty Service 

Members.[ , ] Between 2012 and 2016, pre-term labor, obesity related complications, preeclampsia, 

and GDM affected 17.7%, 9.2%, 6.8%, and 6.3% of live births, respectively. Over the same time period, the 

percentage of live births affected by preeclampsia and GDM remained relatively stable, while the 

percentages of live births affected by preterm labor decreased and the percentage of live births affected 

by obesity-related complications increased.[ ] 

17 20

20

Pregnant Service Members and Veterans more commonly experience mental health issues than nonpregnant Service Members and Veterans or pregnant women in the general population. In a study of 

mental health concerns among women Veterans between 2008 and 2012, anxiety, depression, and PTSD 

were twice as likely among those receiving pregnancy care as those without a pregnancy.[ ] Being 

removed from their support network for military service during deployments and military assignments 

may also affect mental health outcomes of pregnant Service Members. Nearly one in eight women in 

the military (compared to approximately one in nine in the general population) develop postpartum 

depression, possibly reflecting disrupted social support. Postpartum depression can, in turn, be 

21
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complicated by other psychosocial factors, such as poor relationship satisfaction and low selfesteem.[ ] 22-24

Other VA/DoD CPGs provide guidance regarding care for the following conditions:

• Screening and Management of Obesity and Overweight (VA/DoD Obesity CPG)1

• Management of Posttraumatic Stress Disorder and Acute Stress Disorder (VA/DoD PTSD CPG)2

• Management of Major Depressive Disorder (VA/DoD MDD CPG)3

III. About this Clinical Practice Guideline

This guideline represents an important step toward improving the treatment and management of 

pregnant women in the VA and DoD. As with other CPGs, however, challenges remain, including evidence 

gaps, the need to develop effective strategies for guideline implementation, and the need to evaluate the 

effect of guideline adherence on clinical outcomes. This guideline is intended for VA and DoD healthcare 

practitioners including primary care providers, obstetricians, gynecologists, nurses, nurse practitioners, 

care coordinators, midwives, mental health practitioners, cardiologists, dietitians, breastfeeding/lactation 

specialists, physical therapists, and others involved in the care of pregnant Service Members or Veterans.

As elaborated upon in the qualifying statement on page one, this CPG is not intended to serve as a 

standard of care. Standards of care are determined on the basis of all clinical data available for an 

individual patient and are subject to change as scientific knowledge and technology advance and practice

patterns evolve. This CPG is based on information available through May 2017 and is intended to provide a 

general guide to best practices. The guideline can assist care providers, but the use of a CPG must always 

be considered as a recommendation, within the context of a provider’s clinical judgment and patient 

values and preferences, for the care of an individual patient.

A. Methods

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

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

Guideline for Guidelines can be downloaded from . This 

document provides information regarding the process of developing guidelines, including the identification 

and assembly of the Guideline Champions (Champions) and other subject matter experts from within the 

VA and DoD, known as the Work Group and, ultimately, the development and submission of a new or

updated Pregnancy CPG.

1

http://www.healthquality.va.gov/policy/index.asp

The Champions and Work Group for this CPG were charged with developing evidence-based clinical 

practice recommendations and writing and publishing a guideline document to be used by providers 

 

1 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/ 2 See the VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 

Available at: https://www.healthquality.va.gov/guidelines/MH/ptsd/ 3 See the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder. Available at: 

https://www.healthquality.va.gov/guidelines/MH/mdd/
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within the VA/DoD healthcare systems as well as those within the community who treat individuals within 

the VA and DoD. Specifically, the Champions and Work Group members for this guideline were responsible 

for identifying the key questions (KQs) of the most clinical relevance, importance, and interest for the 

management of pregnant women. The Champions and the Work Group also provided direction on 

inclusion and exclusion criteria for the evidence review and assessed the level and quality of the evidence. 

The amount of new scientific evidence that had accumulated since the previous version of the CPG was 

also taken into consideration in the identification of the KQs. In addition, the Champions assisted in:

• Identifying appropriate disciplines of individuals to be included as part of the Work Group

• Directing and coordinating the Work Group

• Participating throughout the guideline development and review processes

The VA Office of Quality, Safety and Value, in collaboration with the Office of Evidence Based Practice, U.S. 

Army Medical Command, the proponent for CPGs for the DoD, identified four clinical leaders, Heather 

Able, MSN, RNC and Alicia Christy, MD, MHSCR, FACOG from the VA and COL Lisa Foglia, MD, FACOG and 

Lt Col Barton Staat, MD, FACOG from the DoD, as Champions for the 2018 CPG. 

The Lewin Team, including The Lewin Group, Duty First Consulting, ECRI Institute, and Sigma Health 

Consulting, LLC, was contracted by the VA and DoD to support the development of this CPG and conduct 

the evidence review. The first conference call was held in October 2016, with participation from the 

contracting officer’s representative (COR), leaders from the VA Office of Quality, Safety and Value and the 

DoD Office of Evidence Based Practice, and the Champions. During this call, participants discussed the 

scope of the guideline initiative, the roles and responsibilities of the Champions, the project timeline, and 

the approach for developing and prioritizing specific research questions on which to base a systematic 

review (SR) about the management of pregnancy. The group also identified a list of clinical specialties and 

areas of expertise that are important and relevant to the management of pregnancy, from which Work 

Group members were recruited. The specialties and clinical areas of interest included: 

breastfeeding/lactation, care coordination, cardiology, clinical psychology, dietetics, family medicine, 

gynecology, internal medicine, mental health, midwifery, nursing, nutrition, obstetrics, psychiatry, 

women’s health, and physical therapy.

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

1. Formulating and prioritizing KQs

2. Convening patient focus groups

3. Conducting the systematic evidence review

4. Convening a face-to-face meeting with the CPG Champions and Work Group members

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

Appendix A provides a detailed description of each of these tasks.

a. Grading Recommendations

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 
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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

 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 

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

.

Recommendations

Appendix A
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b. Reconciling 2009 Clinical Practice Guideline Recommendations

Evidence-based CPGs should be current, which typically requires revisions of previous guidelines based on 

new evidence, or as scheduled and subject to time-based expirations.[ ] For example, the U.S. Preventive 

Services Task Force (USPSTF) has a process for refining or otherwise updating its recommendations 

pertaining to preventive services.[ ] Further, the inclusion criteria for the National Guideline Clearinghouse 

specify that a guideline must have been developed, reviewed, or revised within the past five years. 

25

26

The Pregnancy Guideline Work Group focused largely on developing new and updated recommendations 

based on the evidence review conducted for the priority areas addressed by the KQs. In addition to those 

new and updated recommendations, the Work Group considered, without complete review of the 

relevant evidence, the current applicability of other recommendations that were included in the previous 

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).[ , ] These categories, along with their corresponding definitions, were used to 

account for the various ways in which older recommendations could have been updated. In brief, the 

categories took into account whether or not the evidence that related to a recommendation was 

systematically reviewed, the degree to which the recommendation was modified, and the degree to which 

a recommendation is relevant in the current care environment and within the scope of the CPG. Additional 

information regarding these categories and their definitions can be found in 

. The categories for the recommendations included in the 2018 version of the guideline can 

be found in the section on . The categories for the recommendations carried forward 

from the 2009 Pregnancy CPG are noted in . 

. 

27 28

Recommendation 

Categorization

Recommendations

Appendix D

The CPG Work Group recognized the need to accommodate the transition in evidence rating systems from 

the 2009 Pregnancy CPG to the current CPG. In order to report the strength of all recommendations using 

a consistent format (i.e., the GRADE system) the CPG Work Group converted the USPSTF strengths of the 

recommendation accompanying the carryover recommendations from the 2009 guideline to the GRADE 

system. As such, the CPG Work Group considered the strength of the evidence cited for each 

recommendation in the 2009 Pregnancy CPG as well as the intervention’s harms and benefits, values and 

preferences, and other implications, where possible. The CPG Work Group referred to the available 

evidence as summarized in the body of the 2009 Pregnancy CPG and did not systematically re-assess the 

evidence. In some instances, relevant peer-reviewed literature published since the 2009 Pregnancy CPG 

was considered along with the original evidence base for the specific recommendation. Where such newer 

literature was considered when converting the strength of the recommendation from the USPSTF to the

GRADE system, it is referenced in the discussion that follows the corresponding recommendation, as well 

as in Appendix C

The CPG Work Group recognizes that, while there are sometimes practical reasons for incorporating 

findings from a previous SR, previous recommendations,[ ] or recent peer-reviewed publications into an 

updated CPG, doing so does not involve an original, comprehensive SR and, therefore, may introduce bias. 

29
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c. Peer Review Process 

The CPG was developed through an iterative process in which the Work Group produced multiple drafts of 

the CPG. The process for developing the initial draft is described in more detail in 

. 

Drafting and Submitting 

the Final Clinical Practice Guideline

Once a near-final draft of the guideline was agreed upon by the Champions and Work Group members, 

the draft was sent out for peer review and comment. The draft was posted on a wiki website for a 

period of 14 business days. The peer reviewers comprised individuals working within the VA and DoD 

healthcare systems as well as experts from relevant outside organizations designated by the Work 

Group members. Organizations designated by the Work Group to participate in the peer review and who 

provided feedback include the following:

• Albany Medical Center

• American College of Obstetricians and Gynecologists (ACOG)

• Tufts Medical Center

The VA and DoD Leadership reached out to both the internal and external peer reviewers to solicit their 

feedback on the CPG. Reviewers were provided a hyperlink to the wiki website where the draft CPG was 

posted. All feedback from the peer reviewers was discussed and considered by the Work Group. 

Modifications made throughout the CPG development process were made in accordance with the 

evidence. 

B. Summary of Patient Focus Group Methods and Findings

When forming guideline recommendations, consideration should be given to the values of those most 

affected by the recommendations: patients. Patients bring perspectives, values, and preferences into their 

healthcare experience that can vary from those of clinicians. These differences can affect decision making 

in various situations, and should thus be highlighted and made explicit due to their potential to influence a 

recommendation’s implementation.[ , ] Focus groups can be used as an efficient method to explore 

ideas and perspectives of a group of individuals and collect qualitative data on a thoughtfully 

predetermined set of questions. 

30 31

Therefore, as part of the effort to update this CPG, VA and DoD Leadership, along with the Pregnancy CPG 

Work Group, held two patient focus groups. The first was held on December 1, 2016 at the Washington DC 

VA Medical Center in Washington, DC. The second was held on February 2, 2017 at Malcolm Grow Medical 

Clinics and Surgery Center at Joint Base Andrews, MD. The aim of the focus groups was to further 

understand and incorporate the perspective of pregnant women covered and/or receiving their care 

through the VA and/or DoD healthcare systems during their pregnancy and perinatal period, as pregnant 

women are those most affected by the CPG. The focus groups delved into the patients’ perspectives on a 

set of topics related to their pregnancy care, including their priorities, challenges they have experienced, 

and the information they received regarding their pregnancy care, as well as the impacts of their 

pregnancy and their pregnancy care on their lives. 

It is important to note the focus groups comprised a convenience sample and the Work Group recognizes 

the lack of generalizability and other limitations inherent in the small sample size. Less than 10 people in 
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March 2018 Page 15 of 147

total were included in two focus groups to be consistent with the requirements of the federal Paperwork 

Reduction Act, 1980. The Work Group acknowledges that the sample of pregnant women included in these 

focus groups is not representative of all pregnant women within the VA and DoD healthcare systems. 

Further, time limitations for the focus groups prevented exhaustive exploration of all topics related to 

pregnancy care in the VA and DoD and the women’s broader experiences with their care. Thus, the Work 

Group made decisions regarding the priority of topics to discuss at the focus groups. These limitations, as 

well as others, were considered during guideline development as the information collected from the 

discussion was being used. Recruitment for participation in the focus groups was managed by the 

Champions and VA and DoD Leadership, with assistance from coordinators at the facilities at which the 

focus groups took place.

The following concepts are ideas and suggestions about aspects of care that are important to pregnant 

women and emerged as recurring themes during the discussions ( ). These concepts were important 

parts of the participants’ care and added to the Work Group’s understanding of patient values and 

perspectives. Additional details regarding the patient focus group methods and findings can be found in 

. 

Table 2

Appendix B

Table 2. Pregnancy CPG Focus Group Concepts

Pregnancy CPG Focus Group Concepts

A. Recognize the importance of a support network throughout pregnancy, including as a trusted source of 

information specific to a patient’s unique pregnancy experience (e.g., as a first-time parent or Active Duty 

Service Member)

B. Provide information regarding general pregnancy care to the patient in a timely manner and in a way that is 

responsive to the patients’ goals, values, and preferences

C. Provide comprehensive, understandable information regarding covered services to the patient and help the 

patient navigate that information and answer questions as needed

D. Recognize the importance of the relationship between the patient and her provider and care team and the 

necessity for the patient to have consistency in this relationship and her access to care 

E. Ensure that the family is involved in the pregnancy in accordance with patient preferences and recognize the 

differences among families in structure and composition

F. Ensure that patients know the options for pediatric healthcare and day care early in their pregnancy and 

provide information so that they can feel secure in their planning

G. Improve communication and information sharing between VA and community providers to ensure patients 

receive the individualized care they need without undue stress

C. Conflicts of Interest

At the start of this guideline development process and at other key points throughout, the project team 

was required to submit disclosure statements to reveal any areas of potential conflict of interest (COI) in 

the past 24 months. Verbal affirmations of no COI were used as necessary during meetings throughout 

the guideline development process. The project team was also subject to random web-based 

surveillance (e.g., Centers for Medicare and Medicaid Services open payments or ProPublica). 

If a project team member reported a COI (actual or potential), then it was reported to the Office of 

Evidence Based Practice. It was also discussed with the Pregnancy CPG Champions in tandem with their 

review of the evidence and development of recommendations. The Office of Evidence Based Practice and 

the Pregnancy CPG Champions determined whether or not action, such as restricting participation and/or 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 16 of 147

voting on sections related to the conflict or removal from the Work Group, was necessary. If it was 

deemed necessary, action to mitigate the COI was taken by the Champions and Office of Evidence Based 

Practice, based on the level and extent of involvement. No conflicts of interest were identified for the 

Pregnancy CPG Work Group members or Champions. Disclosure forms are on file with the Department of 

Veterans Affairs Evidence Based Practice Program office and available upon request.

D. Scope of this Clinical Practice Guideline

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

that are recommended in this guideline 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 (e.g., generalized anxiety disorder, PTSD, diabetes mellitus [DM]). 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. 

E. Highlighted Features of this Clinical Practice Guideline

The 2018 edition of the VA/DoD Pregnancy CPG is the second update to the original CPG. It provides 

practice recommendations for the care of women with uncomplicated pregnancies as well as guidance for 

specialty referral. A particular strength of this CPG is the multidisciplinary stakeholder involvement from its 

inception, ensuring representation from the broad spectrum of clinicians engaged in the treatment and 

management of pregnant women with and without co-occurring conditions. 

The framework for recommendations in this CPG considered factors beyond the strength of the evidence, 

including balancing desired outcomes with potential harms of the intervention, equity of resource 

availability, the potential for variation in patient values and preferences, and other considerations (e.g., 

resource use, subgroup considerations) as appropriate. Applicability of the evidence to VA/DoD 

populations was also taken into consideration. An algorithm, in the form of a table, accompanies the 

guideline to provide an overview of the recommendations in the context of the flow of patient care and to 

assist with training providers (see the section ). The algorithm may be used to help facilitate 

translation of guideline recommendations into effective practice. 

Algorithm

F. Patient-centered Care

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

characteristics, experience with previous pregnancies, and preferences. Regardless of setting, all patients 
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in the healthcare system should be able to access evidence-based care appropriate to that patient. When 

properly executed, PCC may decrease patient anxiety, increase trust in clinicians,[ ] and improve 

treatment adherence.[ ] Improved patient-clinician communication and a PCC approach conveys 

openness and supports disclosure of current and future concerns.

32

33

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

with the pregnant woman. They should ask each pregnant woman about any concerns she has or barriers 

to high quality care she might experience. Lastly, they should educate the pregnant women on the actions 

that need to be taken and any decisions that need to be made and should involve the woman in decision

making regarding management of pregnancy.

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. 

G. 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.[ ] 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.

34

H. Co-occurring Conditions

Co-occurring medical and mental health conditions are important to recognize because they can modify 

the management of pregnancy, patient or provider treatment priorities, clinical decisions, and the provider 

with which pregnancy and ongoing healthcare will be provided. Providers should expect that many 

pregnant Veterans, Service Members, and their family will have one or more co-occurring health 

conditions. Because of the nature of pregnancy care, which sometimes takes place in parallel with ongoing 

care for co-occurring conditions, it is generally best to manage pregnancy in collaboration with the care for 

other health conditions that are being treated in primary or specialty care. Some co-occurring medical or 

mental health conditions may require early specialist consultation in order to discuss any necessary 

changes in treatment due to pregnancy or to establish a common understanding of how care will be 

coordinated and delivered. 
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I. Implementation

This CPG and algorithm are designed to be adapted by individual healthcare providers with consideration 

of local needs and resources. The algorithm serves as a tool to prompt providers to consider key decision 

points in the course of an episode of care.

Although this CPG represents the recommended practice on the date of its publication, medical practice is 

evolving and this evolution requires continuous updating based on published information. New technology 

and more research will improve patient care in the future. The CPG can assist in identifying priority areas 

for research and informing optimal allocation of resources. Future studies examining the results of CPG

implementation may lead to the development of new evidence particularly relevant to clinical practice. 
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IV. 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. 
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V. 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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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 and 

.

Standard of Pregnancy Care 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 [ ], exercise 

[ ], weight gain, work schedules [ ], dietary 

supplementation [ ])b 

Recommendation 7

Recommendation 2 Recommendation 3

Recommendation 4

 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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Intervention

 Offer prenatal screening for aneuploidy and common genetic disorders (

and )

Recommendation 8

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 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 ( ); review current vaccination status in accordance 

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

Recommendation 13

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

Assess fetal presentation
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D. Standard of Pregnancy Care

Some aspects of pregnancy care, although clinically important and part of the generally accepted 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 USPSTF determined that the best strategy for preventing preeclampsia in pregnancy 

is early detection through routine blood pressure screening.[ ] A pregnant woman’s blood pressure 

should be measured at every visit.

35

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 and .

36

37

Table 3 Table 4

Table 3. Weight Gain Recommendations for Singletons [ ] 38

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 4. Weight Gain Recommendations for Women Pregnant With Twins [ ] 38

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 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.[ ] 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.[ ] 

39

39

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, GDM), several studies have shown there may be an association 

between periodontal disease and increased risk of adverse pregnancy outcomes.[ , ] Pregnancy is not a 

contraindication to most dental services, though some procedures requiring general anesthesia may be 

deferred to the postpartum period.[ ] 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.[ ] Routine dental care, including x-rays (with proper anatomic shielding) and periodontal 

therapy, along with good oral hygiene, should be encouraged throughout pregnancy.[ , ] 

40 41

42

43

43 44

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.[ ] 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.[ ] 

45

45

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

and even death, with a possible increased spontaneous abortion rate.[ ] 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.[ ] 

46

47

• 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%.[ ] 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.[ ] Neonatal varicella zoster virus (VZV) infection is associated 

with a high neonatal death rate.[

, ] 

48

49

50] 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.[51 52

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

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

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

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

53

54 55

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.[56] 

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 multivitamins and minerals have also been 

associated with improved outcomes. See 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).[ , ] The 

Operation Supplement Safety website ( ) 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.[ , ] 

Recommendation 4

57 58

www.opss.org

59 60

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, 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 [ ]) 61

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.[ ] Appointments with RDNs may not be feasible 

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

62

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

evidence regarding optimal screening times or intervals.

63

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.[ , ] 63 64 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.[65,66] 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).[67] A complete obstetric sonographic examination should be available to all women, 

including those considering an invasive test.[68,69] 

Fetal Presentation

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

treatment.[70] If non-cephalic presentation is suspected, it should be confirmed with ultrasound.[71] Once 

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

discuss external cephalic version to correct malpresentation.[72,73] 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 (VA/DoD DM CPG) for 

more information on diagnostic techniques.4 Women with hypertensive and metabolic diseases of 

pregnancy may have increased risk of long-term health problems, particularly lifetime risk of 

cardiovascular disease (CVD). 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. 

 

4 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/ 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 29 of 147

VI. 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 5. Consideration of antepartum referrals to advanced prenatal care providers 

can be informed by Table 6. 

Table 5. 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
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 30 of 147

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
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 31 of 147

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

March 2018 Page 32 of 147

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 6. 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

March 2018 Page 33 of 147

VII. Recommendations

# 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 Disorders5

and the Management of Tobacco Use6

). 

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

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

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

https://www.healthquality.va.gov/guidelines/mh/sud/ 6 See the Clinical Practice Guideline for the Management of Tobacco Use. Available at: 

https://www.healthquality.va.gov/CPGArchives.asp
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 34 of 147

# Recommendation Strength* Category†

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

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
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 35 of 147

# Recommendation Strength* Category†

Subpopulations (cont.)

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 Grading Recommendations. 

†For additional information, please refer to Recommendation Categorization and Appendix D. 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 36 of 147

A. Care Throughout Pregnancy

a. Routine Care During Pregnancy

Recommendation

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

provider appointments.

(Weak for | Not reviewed, Amended)

Discussion

The 2009 CPG recommended a group model of prenatal care as an acceptable alternative to individual 

provider appointments based on two studies.[74,75] One study, in a university-based setting, 

demonstrated that women assigned to group prenatal care were less likely to experience preterm delivery 

than those receiving standard prenatal care.[74] 

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.[76] However, the study found a potential 

risk reduction of preterm delivery in African American women and did not find any evidence of harm 

through participation in group prenatal care. A limitation of this meta-analysis is that a variety of other 

important outcomes such as patient satisfaction, contraception initiation, and depression were not 

examined. 

A group model of prenatal care may fit better with the values and preferences of some pregnant women 

than the individual model. Patient preferences and values, as well as competing issues such as child care, 

may affect a woman’s choice to pursue individualized care versus care in a group setting. The presence of 

medical or pregnancy complications may also influence a woman’s decision to pursue group prenatal care. 

As this is a Not reviewed, Amended recommendation, the Work Group did not systematically review 

evidence related to this recommendation. Based on the assessment of the quality of the evidence put 

forth in the 2009 Pregnancy CPG,[74,75] the Work Group determined the evidence to be moderate quality 

for offering a group model of prenatal care as an alternative to individual provider appointments. Other 

support for this recommendation stemmed from the benefits outweighing the harms of offering a group 

model of prenatal care as an alternative to an individual model. 

Recommendation

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)

Discussion

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.[77] Studies 

included in the evidence review overwhelmingly used three or more sessions per week.[77-82] In an SR by 

Harrison et al. (2016) outcomes overall seemed to improve with exercise of greater frequency and/or 

intensity with some form of supervision for the purposes of improving adherence.[80] In another SR, by 

Aune et al. (2016), the minimum exercise frequency studied was one time per week to provide sufficient
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 37 of 147

stimulus or aerobic effect with no exercise as the control.[78] Therefore, for better outcomes, providers 

should encourage women to exercise three or more times per week at an intensity level of mild to 

moderate for at least 20 minutes per day, with a goal of 150 minutes per week. Less than 20 minutes per 

day has not been shown to benefit mother or baby.[78] 

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 of preterm birth or shortening 

gestational age at birth.[77] 

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.[83] Further information on exercise intensity can be found 

in the VA/DoD Obesity CPG7 and through the CDC website8. 

The benefits of exercise during pregnancy outweigh harms for most women, as exercise can reduce excess 

maternal weight gain and the incidence of fetal macrosomia in newborns, as well as decrease the rate of 

neonatal respiratory distress, GDM, depression, and cesarean deliveries.[77-82,84,85] There is no evidence 

to suggest that exercise causes preterm births, underweight newborns, stillbirths, or increased incidence 

of shoulder dystocia or induction of labor.[77-82,84,85] Pregnant women may note an increase in uterine 

cramping with moderate exercise or activity; this is rarely problematic, as long as the cramping ceases with 

termination of activity.

Many women are concerned about risks associated with exercise during pregnancy and are unclear about 

what types of exercise are safe for them and their babies. Therefore, women need to be educated that 

moderate intensity exercise can be safely continued during pregnancy as long as symptoms of preterm 

labor do not arise. 

Many types of exercise were included in the studies identified through the systematic review. Exercise 

included aerobic, strength training, or a combination of both. It was supervised, in groups, or in 

independently led programs. Pre-pregnancy fitness levels of participants ranged from sedentary to 

athletic. The type of exercise a woman chooses may vary but is best and most sustainable if worked into 

a woman’s lifestyle. 

Obstetric contraindications to aerobic exercise include incompetent cervix or cerclage, multiple gestation, 

at risk of preterm labor, persistent second or third trimester bleeding, placenta previa after 26 weeks 

gestation, preterm labor during the current pregnancy, and ruptured membranes.[85] Maternal 

contraindications to aerobic exercise include hemodynamically significant heart disease and restrictive 

lung disease.

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

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

 

7 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/ 8 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

March 2018 Page 38 of 147

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.[85] 

Some types of exercise have other benefits. For example, there is moderate quality evidence to support 

the use of yoga in reducing depression scores during pregnancy in women with or without a diagnosis of 

prenatal depression. Integrative yoga that may or may not incorporate physical exercise, includes some 

type of deep breathing or controlled breathing (i.e., pranayama), and includes meditation is more effective 

than exercise-based yoga alone.[84] 

There is moderate to low quality evidence that some activities and positions should be avoided, such as 

high-altitude activities (>10,000 feet), prolonged supine positions, Valsalva maneuver, scuba diving, 

contact sports, or activities that increase the risk for abdominal injuries such as soccer, baseball, 

basketball, and horseback riding.[85,86] 

As noted in the 2009 Pregnancy CPG, there is no evidence that sexual intercourse increases the probability 

of preterm labor in women with uncomplicated pregnancy.[87] Some women may see sexual intercourse 

as a strenuous aerobic activity. They may experience some uterine contractions following orgasm; 

however, this is a normal response and women only need to seek medical attention if uterine contractions 

persist at four or more per hour for at least three hours or if heavy vaginal bleeding is noted. 

Based on the assessment of the quality of the evidence identified in the 2017 systematic evidence review 

conducted for this CPG update [77-82,84,85] as well as the quality of the evidence cited in the 2009 

Pregnancy CPG,[87] the Work Group determined confidence in the quality of the evidence was high in 

support of participation of pregnant women in regular mild to moderate exercise sessions. Other support 

for this recommendation stemmed from the benefits of regular aerobic exercise outweighing the harms. 

Recommendation

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

throughout their pregnancy.

(Weak for | Not reviewed, Amended)

Discussion

If a pregnant woman’s work is strenuous or if she spends long periods of time on her feet, she should limit 

her work week to 40 hours and workday to eight hours during the last trimester (beginning at 28 weeks) or 

earlier, if she frequently experiences symptoms of preterm labor while at work. Strenuous work is defined 

as work involving industrial machines or conveyor belts, significant physical exertion or load carrying, or 

prolonged adverse conditions such as cold temperatures, wet atmosphere, or the manipulation of 

chemical substances.[88] 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.[88-91] 

Pregnant women should attempt to limit time on their feet to three hours at a time. 

Active Duty Service Members should continue to follow their service-specific profiling regulations. Before a 

specific recommendation can be made regarding particular work limitations, further high-quality studies 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 39 of 147

are needed to examine the association between strenuous or prolonged work activities and adverse 

pregnancy outcomes. No changes to the current service branch guidelines are suggested as an updated 

systematic review was not conducted and no new evidence was reviewed for this recommendation. 

As this is a Not reviewed, Amended recommendation, the Work Group did not systematically review 

evidence related to this recommendation. Based on the assessment of the quality of the evidence put 

forth in the 2009 Pregnancy CPG, including peer-reviewed publications [88-91] and a publication from 

another organization,[92] the Work Group determined confidence in the quality of the evidence was 

moderate for offering a group model of prenatal care as an alternative to individual provider 

appointments. One publication from another organization that was included in the evidence base for the 

2009 CPG [92] has been updated.[93] The Work Group determined that benefits of this recommendation 

slightly outweigh the harms for women with uncomplicated pregnancies. A weak recommendation was 

made due to the considerations that need to be made for women with occupations that require strenuous 

activity or prolonged periods of standing, for whom the balance of benefits and harms may be different.

b. Nutrition

Recommendation

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)

Discussion

The recommendation for a pregnant woman to supplement her diet with folic acid beginning one month 

before conception and continuing throughout pregnancy and breastfeeding is based on support cited in 

the 2009 Pregnancy CPG [94] as well as relevant USPSTF recommendations.[95,96] 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.[97-99] Folic acid supplementation has not been found to be associated with serious 

harms.[95,96] Women prescribed folate antagonists (e.g., antiepileptic, antimalarial, methotrexate) may 

require doses of folic acid higher than the CDC-recommended minimal daily dose of 400 micrograms. For 

women taking antiepileptic drugs, clinicians should defer to the manufacturer’s recommended dosing for 

folic acid. Women who have had an NTD-affected pregnancy and who are planning on becoming pregnant 

should take higher levels of folate daily (i.e., 4 milligrams daily). These women should also consume 0.4 mg 

(400 micrograms) of folic acid every day when not planning to become pregnant.[100] 

Folic acid supplements are widely available without prescription and generally over the counter. They are 

also safe and relatively inexpensive. Providers should educate their patients about their options regarding 

supplementation. In addition to folic acid supplements, women should also be educated on the benefits of 

eating a folate-rich diet.

As this is a Not reviewed, Amended recommendation, the Work Group did not review evidence related to 

this recommendation. Based on the assessment of the quality of the evidence put forth in the 2009 

Pregnancy CPG,[57,58,94,97,98,101-103] the Work Group determined confidence in the quality of the 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 40 of 147

evidence was high in support of supplementing the diet of a pregnant woman with folate. One systematic 

review that was included in the evidence base for the 2009 CPG [98] has been updated.[99] Other 

support for this recommendation stemmed from the benefits of supplementation outweighing the harms. 

The benefits of folic acid supplementation, including reducing risk of NTDs which carry significant harm, 

are well documented, which led to a “Strong for” recommendation. 

c. Screening

Recommendation

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 Disorders9 and the 

Management of Tobacco Use10). 

(Strong for | Reviewed, Amended)

Discussion

Background on Substance Use During Pregnancy

Substance use during pregnancy can influence fetal and maternal outcomes. Tobacco, alcohol, cannabis, 

and illicit drugs are the most commonly used substances during pregnancy.[104] The 2013 National Survey 

on Drug Use and Health (NSDUH) found that among pregnant women aged 15-44 in 2012-2013, 9.4% 

reported current alcohol use, 2.3% reported binge drinking, and 0.4% reported heavy drinking. More than 

15% (15.4%) of pregnant women smoked cigarettes and 5.4% of pregnant women used illicit drugs.[105] A 

report developed based on combined data from a series of Substance Abuse and Mental Health Services 

Administration (SAMHSA) data sets stated that pregnant women (ages 15-44) reported less frequent nonmedical use of opioids in the previous month than non-pregnant women (0.9% versus 2.6%).[106] 

Substance use among Veterans may be higher than in the general population. Among women Veterans of 

child-bearing age, it was estimated that 27-43% have had heavy episodic drinking (defined as four or more 

standard drinks on at least one occasion), 24-26% have had daily cigarette use, 12-29% have reported illicit 

drug use in the past year, and 6-14% have reported misuse of prescription drugs.[107] 

Consequences of Prenatal Exposure to Substances

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

effects. However, other risky behaviors (e.g., use of multiple substances, lack of prenatal care, and other 

stressors in the antepartum) confound attempts to assign causality.[108] 

• Best available evidence indicates that prenatal smoking may impact pregnancy outcomes by 

limiting fetal growth as manifest by low birth weight, reduced birth length, or reduced head 

circumference. A modest increase in the rate of fetal anomalies has also been described.[108] 

Maternal smoking is associated with cardiovascular/heart defects, musculoskeletal defects, limb 

 

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

https://www.healthquality.va.gov/guidelines/mh/sud/ 10 See the Clinical Practice Guideline for the Management of Tobacco Use. Available at: 

https://www.healthquality.va.gov/CPGArchives.asp 
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March 2018 Page 41 of 147

reduction defects, craniosynostosis, facial defects, eye defects, orofacial clefts, gastrointestinal 

defects, gastroschisis, anal atresia, hernia, and undescended testes in exposed infants.[109] 

• Alcohol is a known teratogen. The effects of prenatal alcohol exposure are wide-ranging and 

reflect extent of exposure and susceptibility. Prenatal alcohol exposure causes several 

abnormalities with the heart, kidney, liver, gastrointestinal tract, endocrine system, and the 

brain.[110] The term fetal alcohol spectrum disorder (FASD) describes the broad range of 

adverse sequellae of fetal alcohol exposure, with fetal alcohol syndrome (FAS) and its 

characteristic triad of problems with facial features, growth, and central nervous system as its 

most severe expression.

• The risks of prenatal cannabis exposure are unknown. To date, cannabis has not been 

definitively associated with human teratogenicity nor specific enduring effects in childhood or 

adolescence.[108] 

• Opioids in general have not been considered teratogenic, although a higher incidence of 

congenital anomalies in infants born to mothers exposed to codeine, methadone, or heroin has 

been reported.[108] In utero exposure to opioids is associated with neonatal abstinence 

syndrome (NAS), defined as a constellation of symptoms in newborns including central nervous 

system irritability, gastrointestinal dysfunction, and temperature instability.[111] The incidence 

of NAS has increased almost 300% from 1999 to 2013, reflecting increases in use of opioid 

prescription medications and heroin among women of reproductive age.[112,113] 

Challenges in Identification

The DoD screens Active Duty Service Members for drug use. The VA conducts universal screening for 

alcohol and tobacco use but not for other substances. The standard threshold for the Alcohol Use 

Disorders Identification Test- Consumption (AUDIT-C) screening tool is not adjusted for gender.[107] 

Moreover, there is no safe drinking limit during pregnancy.[114] The reference standard for the detection 

of prenatal alcohol exposure is maternal self-reporting.[115] Women may be less likely than men to 

disclose alcohol use to a primary care provider, resulting in women being less likely to receive effective 

intervention.[116] There is no reliable laboratory test to screen for alcohol use in pregnancy.[115,117] 

Because there are potential legal and other consequences when positive biological tests are found, 

informed consent must be obtained prior to their utilization, except in the case of a medical emergency 

when the pregnant woman is unconscious and unable to consent.

Summary

Antepartum use of alcohol, cigarettes, illicit drugs, or unauthorized use of prescription medication in this 

period is not uncommon, and may be associated with adverse effects. Hence, we recommend screening 

for tobacco, alcohol, illicit drugs, and non-prescribed use of medication, followed by additional evaluation 

and treatment based on screening results. See the VA/DoD Clinical Practice Guideline for the Management
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March 2018 Page 42 of 147

of Substance Use Disorders (VA/DoD SUD CPG)11 and the Management of Tobacco Use (VA/DoD Tobacco 

Use CPG)12. 

As this is a Reviewed, Amended recommendation, the Work Group systematically reviewed the evidence 

identified in the evidence review conducted for this CPG update [118] and considered the assessment of 

the evidence put forth in the 2009 CPG.[119-128] The Work Group determined confidence in the quality of 

the evidence was moderate in support of screening pregnant women for use of alcohol, tobacco, or illicit 

drugs or unauthorized use of prescription drugs. One systematic review that was included in the evidence 

base for the 2009 CPG [120] has been updated.[129] The Work Group determined that benefits of this 

recommendation outweigh the harms for pregnant women and their newborns.

Recommendation

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) 

Discussion

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.[130] Providers should screen patients periodically, 

such as at first presentation, week 28, and at the postpartum visit. Potential harms of screening include 

time spent on screening and discomfort with screening questions. Benefits of screening for depression 

outweigh harms, 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. VA/DoD patient focus group findings suggest that pregnant women want to discuss 

mental health concerns with their clinicians and do not object to depression screening (see Patient Focus 

Group Methods and Findings). This is congruent with research findings that perinatal depression screening 

is acceptable to most women.[131] Screening tools and mental health treatment resources are available in 

the VA and DoD.

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. The PHQ-9 is readily available in all 

VA and DoD clinical settings; the EPDS is more commonly used in perinatal care settings. In a randomized 

controlled trial (RCT) comparing these two screening tools, moderate quality evidence suggests 83% 

concordance between the two scales when scores are dichotomized between “normal” and “increased risk 

of depression.”[132] Concordance is greatest at the highest score levels, and concordance for suicidal 

thoughts is very high. More research is needed to determine the optimal screening tool. Evidence to date 

suggests that screening produces better outcomes than no screening, regardless of which screening tool is 

 

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

https://www.healthquality.va.gov/guidelines/mh/sud/ 12 See the Clinical Practice Guideline for the Management of Tobacco Use. Available at: 

https://www.healthquality.va.gov/CPGArchives.asp 
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used. If used alone, the PHQ-2 (first two items of the PHQ-9) has less specificity; following up with the full 

PHQ-9 improves specificity with no loss of sensitivity. 

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

anxiety disorders, or 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. More information can be found in the VA/DoD PTSD 

CPG13 and the VA/DoD MDD CPG14. Additionally, Massachusetts Child Psychiatry Access Project (MCPAP) 

for Moms offers information and tools providers can use in the prevention, identification, and treatment 

of depression and other mental health conditions.15

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation in the evidence review conducted as part of this guideline update.[132] 

The Work Group determined confidence in the quality of the evidence was moderate in support of 

screening for depression. Other support for this recommendation stemmed from the benefits of this 

recommendation outweighing the harms, as the perinatal period is a higher risk time for developing 

depression, and untreated perinatal depression poses risks to offspring as well as risks to the mother. 

d. Education

Recommendation

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 openended questions such as “What do you know about breastfeeding?”

(Strong for | Reviewed, New-replaced)

Discussion

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

and exclusive breastfeeding for at least six months.[133] The health benefits of breastfeeding for both the 

mother and the newborn have been well-documented. 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.[134,135] However, the various ways in which clinicians instruct their patients 

about breastfeeding differs immensely across clinical settings. What seems to be clear is that the 

education should start prenatally (ideally at the first visit), be continued throughout the pregnancy, and 

include the pregnant woman’s family or chosen support people. Breastfeeding education can be provided 

in individual appointments or through a group model of prenatal care (see Recommendation 1).

Breastfeeding education should be tailored to the needs and resources of the community. A provider 

should approach the topic with sensitivity and foster a supportive environment. A breastfeeding education 

program which used open-ended questions focusing on the woman’s beliefs about breastfeeding was 

 

13 See the VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 

Available at: https://www.healthquality.va.gov/guidelines/MH/ptsd/ 14 See the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder. Available at: 

https://www.healthquality.va.gov/guidelines/MH/mdd/ 15 See the Massachusetts Child Psychiatry Access Project (MCPAP) for Moms website. Available at: 

https://www.mcpapformoms.org/ 
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effective in increasing breastfeeding.[136] 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, and 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. 

According to cohort studies by Fairlie et al. (2009) and Wouk et al. (2016), women who experience anxiety 

and depression during pregnancy are just as likely to initiate breastfeeding as women who do not, while 

those who experience anxiety or depression in the postpartum period are far less likely to continue 

exclusive breastfeeding.[137,138] By providing additional support, providers may be able to identify and 

address potential breastfeeding challenges for women over the course of their pregnancy and thus 

increase the number of women who are exclusively breastfeeding.

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation in the evidence review conducted as part of this guideline 

update.[137,138] The Work Group determined confidence in the quality of the evidence was moderate in 

support of breastfeeding education, assessment, and support. Other support for this recommendation 

stemmed from the benefits of breastfeeding support outweighing the harms.

B. One-time Interventions

a. Screening and Diagnostic Testing

Recommendation

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

(Weak for | Reviewed, New-replaced)

Discussion

There are no RCTs or SRs 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 

Pregnancy CPG Work Group acknowledges that this recommendation is based, in part, on consensus and 

expert opinion from ACOG and the Society for Maternal-Fetal Medicine (SMFM);[139,140] therefore it is 

the accepted standard of care, and the Work Group determined this recommendation was appropriate for

inclusion in the CPG. 

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

informed pregnancy and birth management decisions. Some women may choose to electively terminate 

their pregnancies based on these results. For women who choose to continue their pregnancies, early 

diagnostic testing affords the opportunity to learn about the diagnosis and prepare for the birth and the 

neonatal period. It also facilitates earlier consultation with other pediatric subspecialists (e.g., 

developmental pediatricians). Offering prenatal diagnostic testing, regardless of maternal age or risk 

factors, respects the values and preferences of women who make this choice. The potential harms include 

the small, but known, risk of pregnancy loss, which is about 1/455 (0.22%) for chorionic villus sampling 
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(CVS) and about 1/900 (0.1%) for amniocentesis.[141] 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.[142] 

There may be increased costs associated with prenatal diagnostic testing. Because some facilities do not 

offer CVS and/or amniocentesis, pregnant women may be referred to outside facilities to obtain testing. 

This will likely increase out-of-pocket and/or travel costs. 

Based on the assessment of the quality of the evidence identified in the 2017 evidence review as well as 

on the assessment of the quality of the evidence put forth in the 2009 Pregnancy CPG, which included 

peer-reviewed publications [143-148] and a publication from another organization,[139] the Work Group 

determined overall confidence in the quality of the evidence was low in support of making prenatal 

diagnostic testing available. ACOG and SMFM published an updated version [140] of the publication 

included as evidence in the 2009 CPG.[139] The recommendation is, in part, based on consensus and 

expert opinion from ACOG and SMFM, rather than prospective studies. The 2017 evidence review did not 

identify any new studies that showed a direct benefit of invasive testing; however, the availability of 

prenatal diagnostic testing for all patients, regardless of age, supports patient autonomy and may be 

beneficial to patients in making pregnancy and birth management decisions. 

Future research should examine the characteristics of pregnant women most likely to choose invasive 

diagnostic testing, especially those who do not have a known increased risk for fetal genetic disorders. The 

optimal method to educate pregnant women about the growing list of prenatal testing options should be 

continuously re-evaluated, as the information and testing options continue to increase in complexity. 

Finally, the optimal test (e.g., karyotype, targeted micro-array, genome-wide array) in the low-risk patient 

is not known.

Recommendation

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)

Discussion 

Some women strongly desire prenatal screening for aneuploidy and other genetic disorders to guide 

management of their pregnancy. Others do not desire this screening. The benefits of testing are that, if the 

testing is positive, women have time to become educated about having a child with a genetic disorder. 

They also have an opportunity to consult with providers who may be involved in the care of their child, 

such as developmental pediatricians. Benefits may be greatest for women who are at high risk of 

aneuploidy (e.g., greater maternal age). Risks of aneuploidy screening include false positive and negative 

results, potential pregnancy loss if patients subsequently pursue invasive diagnostic testing, and maternal 

anxiety from testing. The benefits and harms of aneuploidy screening should be discussed with all patients 

with the ultimate decision taking into account patient’s individual preferences and personal values.
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There are multiple aneuploidy screening tests available. Some screening tests assess analytes in the 

maternal serum independently (e.g., quad screen, serum integrated screen) or in conjunction with 

assessment of nuchal translucency (e.g., integrated screen, first trimester screen, sequential screen). Some 

assess placental DNA in the maternal circulation (e.g., cell-free fetal deoxyribonucleic acid [cffDNA] 

screen). 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.

cffDNA screening has the highest sensitivity and specificity of the available screening tests for Down 

syndrome in high-risk women.[149-154] The test also screens for trisomy 18 and trisomy 13, but has lower 

detection rates for these conditions. Though cffDNA has a lower false positive rate than traditional serum 

screening, the positive predictive value (chance that a positive test is a true positive) depends on the 

patient’s a priori risk of having the condition. The positive predictive value should be calculated and 

provided as part of pre- and post-test counseling. Another potential risk of cffDNA is receiving a nondiagnostic test result. This may be due to low fetal fraction or the presence of other chromosomal 

conditions. Women with non-diagnostic test results will require further evaluation and counseling, which 

can potentially increase costs and use of services, and maternal anxiety. cffDNA screening carries a risk of 

identifying undiagnosed genetic disorders or carcinomas in the mother and identifying non-paternity or 

consanguinity in tests using single nucleotide polymorphism technology. This test can also identify fetal 

gender, which some pregnant women may not wish to know prior to birth. Women who have undergone 

in-vitro fertilization with donor eggs may be candidates for this test; providers should understand test 

recommendations and limitations prior to ordering.

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

field of prenatal screening is rapidly evolving, and gaps in both patient and provider understanding are 

anticipated. There will also be emerging technologies that outpace CPG updates. The Work Group 

acknowledges that serum screening has the ability to identify a broader scope of conditions than cffDNA 

screening, including for example Smith-Lemli-Opitz symdrome and unexplained elevated alphafetoprotein, for which younger women may be at greater risk than aneuploidy. This limitation should be 

addressed as part of pre-test counseling and included as part of a woman’s decision on which screening 

test they choose. Finally, the predictive value of cffDNA testing is dependent upon maternal age, with 

greater predictive values for aneuploidy as maternal age increases, due to the greater prevalence of 

aneuploidy with advancing age. Its utility in younger patients, who have a lower prevalence of 

aneuploidy, may not be cost-effective and patient’s individual desires and values should be factored into 

the decision on which screening test to complete.

The optimal provider type to counsel women about prenatal screening options is unknown; however, 

there are not enough genetic counselors available to conduct pre-test counseling for all pregnant women. 

Due to the rapid expansion and availability of genetic testing, there is a significant need for increased 

provider education to provide adequate patient counseling. The Work Group acknowledges that the field 

of prenatal genetic screening is rapidly evolving; patient and provider understanding, test availability, and 

cost considerations may vary widely and are likely to change. The Work Group acknowledges that there 
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are additional recommendations from professional societies to offer carrier screening to all pregnant 

women for specific genetic conditions (e.g., cystic fibrosis, spinal muscular atrophy, hemoglobinopathies). 

Such tests if performed, do not need to be repeated in each pregnancy. Counseling should include residual 

risk estimates of having an affected child.

The rate of uptake of prenatal screening based on place of care and provider type (e.g., academic military 

treatment facilities versus community-based military treatment facilities versus purchased care) should be 

examined to improve understanding of current prenatal screening strategies. This may, in turn, help 

improve screening services. Limitations of non-invasive prenatal screening should also be examined. 

Evaluation of provider proficiency in counseling and understanding of rapidly evolving technologies as 

related to prenatal screening is critical. Determining the effectiveness of individual versus group-based 

counseling versus other modalities such as web-based counseling will also guide approaches to counseling 

moving forward. 

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed 

evidence related to this recommendation in the evidence review conducted as part of this guideline 

update.[149-154] The Work Group determined confidence in the quality of the evidence was moderate 

in support of using cffDNA screening if aneuploidy screening is desired. As women have varying 

preferences regarding aneuploidy screening, the Work Group recommends offering the screening and, if 

desired, selecting the test with the best performance based on maternal age, risk factors, and test 

performance for a specific condition. 

Recommendation

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)

Discussion

Background

GDM is defined as marked impairment of glucose metabolism initially identified during pregnancy. 

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. Treatment aimed at normalizing glucose metabolism 

has been shown to reduce these risks. Therefore, any pregnant woman with GDM should have additional 

surveillance and management beyond the scope of this guideline.

Testing

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

diagnosed using a two-step process.[155-157] The first step is the administration of a one-hour 50-gram 

non-fasting oral glucose challenge test (GCT) (which includes a blood draw). The typically accepted upper 

limit for this one-hour screen ranges between 130 and 140 mg/dL. Women who are outside this 

acceptable range will require the second step. 
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The second step (for women who screen positive in the first step) is the diagnostic fasting three-hour 

100-gram glucose tolerance test (GTT). There are two acceptable sets of threshold values for this threehour screen that can be used to diagnose GDM. The older criteria defined by the National Diabetes Data 

Group (NDDG) (1979) considers the test positive and the pregnant woman to have GDM if at least two 

of the four values are equal to or exceed 105 mg/dL, 190 mg/dL, 165 mg/dL, and 145 mg/dL for the 

fasting, one-hour, two-hour, and three-hour specimens, respectively.[158] The Expert Committee on the 

Diagnosis and Classification of Diabetes Mellitus has proposed alternate values, which are believed to 

more closely approximate the original Carpenter and Coustan (1982) criteria of 95 mg/dL, 180 mg/dL, 

155 mg/dL, and 140 mg/dL for the fasting, one-hour, two-hour, and three-hour specimens, 

respectively.[159,160] There is currently insufficient evidence-based comparison data to recommend 

one set of criteria over the other. There is a growing body of evidence, albeit insufficient at this time, to 

suggest a simplified testing schema in the future. 

Rationale

Moderate quality evidence suggests that the benefits of screening slightly outweigh the harms/burden 

of screening, but universal consensus has not been reached on that point. Benefits of screening include 

early, appropriate diagnosis and treatment for those pregnant women requiring insulin and the 

resultant avoidance of DM-related complications. Specifically, early, appropriate treatment may lead to 

a reduction in hypertensive disorders in pregnancy, a decrease in cesarean deliveries, and a decrease in 

macrosomia.[161] Harms associated with testing include treatment with insulin for those who would not 

necessarily develop these complications, as well as the time and expense of both counseling and 

treatment. 

There is modest variation in patient preference regarding screening, as some patients may wish to avoid 

blood draws or may not want to wait for a three-hour GTT. However, the majority of patients value GDM 

screening and will return for testing if educated by their providers about the benefits of testing. Those who 

are informed of an abnormal value and do not return for the three-hour test may lack the proper 

education about testing, may be unable to invest the time for a three-hour GTT, or may want to avoid 

multiple blood draws. In a pilot study by Scifres et al. (2015), which also examined patient and provider 

preferences on GDM, 94% of the providers surveyed believed screening women for GDM was important 

and 92% of those providers recommended the current two-step strategy.[162] In contrast, patients 

preferred the two-hour, 75-gram oral GTT, in the absence of a provider recommendation to the contrary. 

Glycosylated hemoglobin (HbA1c) lacks both sensitivity and specificity to serve as an adequate screening 

tool.[163] 

The Work Group further acknowledges that the need for resources varies directly with the number of 

women tested. With an increase in diagnoses of GDM, referral to RDNs will be appropriate. Depending on 

the degree of blood sugar control in a particular woman, additional prenatal visits and maternal and fetal 

surveillance and other services may also be indicated.

Women with Risk Factors for Gestational Diabetes Mellitus

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]) [164] may benefit from earlier 
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screening and treatment, but should be re-screened at 24-28 weeks if initial testing is normal. Women 

with a one-hour GCT value >200 mg/dL may be treated presumptively for GDM without a confirmatory 

test. Women with, or at high risk of, dumping syndrome following gastric bypass surgery may benefit from 

screening for GDM with a fasting and two-hour postprandial glucose values rather than an oral glucose 

load. 

Summary and Future Research

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation in the evidence review conducted as part of this guideline 

update.[161,162] The Work Group determined confidence in the quality of the evidence was moderate in 

support of the two-step process to screen pregnant women for GDM. Other support for this 

recommendation stemmed from benefits of screening slightly outweighing harms and patient values and 

preferences. Future research is needed to definitively demonstrate whether a single two-hour oral GTT 

would be sufficient to diagnose GDM and adequate to replace the two-step process. 

b. Imaging

Recommendation

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)

Discussion

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 (LMP) is often used to estimate gestational age but may be unreliable.[165] 

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

gestational age than menstrual dating. Ultrasound assessment is limited by the implicit assumption that 

below a certain gestational age all fetal size variability is due to gestational age, which can lead to 

systematic under-estimation of gestational age among pregnancies exhibiting early growth restriction 

measured in later scans. However, this is less of a concern for very early ultrasound scans given that 

variation in fetal size is minimal during the first trimester of pregnancy. 

A large prospective study by Hoffman et al. (2008) followed 1,867 participants who were required to 

report the month and day of LMP and undergo first-trimester transvaginal ultrasounds.[165] This study 

suggests that early reporting of LMP results in similar gestational age dating as that obtained from early 

ultrasound. However, when discrepant, the LMP estimate of gestational age tended to be greater than 

ultrasound-based gestational age and resulted in a higher proportion of births being classified as postterm. Inaccurate determination of gestational age may lead to suboptimal planning of care throughout 

the pregnancy. 

Another large prospective study (3,760 participants) by Verburg et al. (2008) compared gestational age at 

birth using estimates from LMP versus ultrasound imaging.[166] The study provided charts for ultrasound 
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dating of pregnancy based on crown-rump length and biparietal diameter and concluded that first 

trimester ultrasounds, preferably between 10 and 12 weeks, are better for the prediction of gestational 

age. 

As this is a Reviewed, New-replaced recommendation, the Work Group systematically reviewed evidence 

related to this recommendation in the evidence review conducted as part of this guideline 

update.[165,166] The Work Group determined confidence in the quality of the evidence was moderate in 

support of first-trimester ultrasound to establish or confirm the gestational age and estimated birth date. 

Other support for this recommendation stemmed from benefits of this recommendation outweighing the 

harms. Benefits include improved timing of planned births and avoidance of post-term birth complications. 

There is some variation in patient and provider preferences regarding first-trimester ultrasound. Access 

issues may make it difficult for some patients to get an ultrasound, particularly in rural or resource-poor 

settings. Future research priorities include how the quality and accuracy of the dating ultrasound are 

affected by provider level or characteristics (e.g., practitioner and specialty type, training, qualifications).

c. Preparing for Delivery

Recommendation

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)

Discussion

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

perinatal complication. A Cochrane review by Gulmezoglu et al. (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.[167] Perinatal complications after 41 weeks gestational age 

have also been documented to include asphyxia, fetal distress, sepsis, and meconium aspiration.[167,168] 

In addition, there has been a documented increased risk of intrauterine death after 37 and 0/7 weeks 

gestation in pregnancies complicated by high maternal age (≥35 years) and in women with high BMI.[169] 

Consistent with these findings, the Work Group recommends that women who reach 41 and 0/7 weeks be 

offered planned delivery. There is moderate confidence in the quality of the current evidence that women 

of all ages reduce the negative neonatal outcomes by delivering before 41 and 0/7.[170] 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.[171,172] 

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. The costs associated with induction include increased 

length of hospital stay and increased nursing contact time versus costs incurred by outpatient monitoring 

followed by induction if spontaneous labor does not occur. However, medical costs and resource 

allocation associated with perinatal complications are also high, making this approach valuable in reducing 

negative outcomes and costs. Some patient variability in values will be noted in this approach as some 
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women highly value deliveries without intervention and have limited time for antenatal monitoring. These 

women may find this approach less acceptable than those that highly value the reduction of risk. As noted 

above, women with complicated pregnancies comprise a higher risk subgroup that may have more 

negative outcomes at an earlier gestational age and should be treated separately.

As this is a Reviewed, Amended recommendation, the Work Group systematically reviewed the evidence 

identified in the evidence review conducted for this CPG update [170] and considered the assessment of 

the evidence put forth in the 2009 CPG.[171-174] The Work Group determined confidence in the quality of 

the evidence was moderate in support of a strong recommendation to offer scheduled delivery for women 

who reach 41 weeks and 0/7 days undelivered. Other support for this recommendation stemmed from the 

benefits of this recommendation, which include improved delivery outcomes, outweighing the harms.

d. Postpartum Care

Recommendation

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)

Discussion

Pregnancy is often referred to as a “stress test” as it relates to the cardiovascular and metabolic systems of 

the mother. 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. Over the past few 

decades, it has become increasingly apparent that 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. Evidence reviewed in development of this recommendation included 

analyses of three SRs [175-177] and 12 individual cohort or case-control studies [178-189] that evaluated 

the potential association between pregnancy complications (preeclampsia, gestational hypertension, and 

GDM) and adverse lifetime health outcomes (CVD, DM, and rheumatoid arthritis). The overall quality of 

evidence supporting an association between hypertensive conditions of pregnancy, preeclampsia and 

GDM was determined to be moderate.

Although these conditions may become quiescent during the postpartum period, there is a breadth of 

epidemiologic evidence that long-term increase in cardiovascular and metabolic risk exists that clinically 

manifest many years later. Recognition of these adverse pregnancy risk factors as markers for future 

health risk is important, as women in their childbearing years are often otherwise healthy and it may not 

be obvious to most providers to consider screening for hypertension and DM in such women. There are no 

studies assessing the effect of specific interventions to modify this risk. There may be potential benefit to 

periodic screening (e.g., yearly screening for DM and hypertension) and lifestyle modifications; however, 

future research is needed. Studies have shown that many providers in primary care and obstetrics underrecognize these adverse pregnancy conditions.[190] Initiatives to increase awareness amongst those 
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working in various specialties as well as a broad range of providers including nursing, physicians, and 

women’s health providers are in progress. 

Primary care providers should obtain a reproductive history yearly in women of childbearing age; a onetime assessment in women who are postmenopausal without prior history of 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.

It is recommended that women with a history of acute pulmonary edema, often associated with other 

conditions such as preeclampsia or magnesium sulfate toxicity, be encouraged to have a follow-up visit in 

primary care. Documentation of an episode of acute pulmonary edema should be added to the patient’s 

problem list and be readily accessible. The importance of follow-up and discussion of such acute 

pulmonary edema conditions with a general follow-up provider should be stressed, as most pregnant 

women would be receptive to prevention of CVD and DM. 

As this is a Reviewed, New-added recommendation, the Work Group systematically reviewed evidence 

related to this recommendation in the evidence review conducted as part of this guideline update.[175-

189] The Work Group determined confidence in the quality of the evidence was moderate in support of 

documenting pregnancy history and making pregnant women aware about the lifetime risk of these 

conditions. Other support for this recommendation stemmed from the benefits of this recommendation, 

which include the potential to improve care, outweighing the harms.

Several areas of future research would be helpful in this area in regards to timing of screening and specific 

interventions for these women. Additionally, there is increasing evidence for association between other 

adverse pregnancy conditions, such as premature births and recurrent miscarriage, and long-term 

cardiovascular risk. There is also some suggestion that adverse pregnancy conditions may also increase 

rheumatologic risk, specifically rheumatoid arthritis; however, definitive evidence to support this is lacking. 

This, along with specific use of intervention therapies such as anti-hypertensives, should be considered as 

a focus for future prevention trials. 

C. Referral

Recommendation

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)

Discussion

This recommendation was carried forward from the 2009 Pregnancy CPG and is based on publications that 

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 alphafetoprotein.[139,191,192] Counseling about these findings should be conducted by an obstetric provider 
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who is able to discuss the meaning of an unexplained elevated maternal serum alpha-fetoprotein (MSAFP) 

and arrange for appropriate follow-up. 

An SR and meta-analysis published since the completion of the evidence review conducted for the 2009 

Pregnancy CPG concludes that elevated MSAFP is a risk factor for the pregnancy complications of 

preeclampsia and low birth weight.[193] This study did not examine other outcomes of importance to 

patients and providers, such as spontaneous preterm labor, stillbirth, or preterm premature rupture of the 

membranes.

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

pregnant women with elevated MSAFP would undergo heightened surveillance and possible earlier 

detection of preeclampsia or fetal growth restriction. This may also identify a specific subgroup of 

pregnant women who may receive better protection from the use of prophylactic aspirin for prevention of 

preeclampsia. One potential harm is that the subgroup of women who will experience complications 

cannot be predicted. Further, knowledge of the test results and increased surveillance may heighten 

anxiety, and place the pregnant woman at risk for increased, and potentially unnecessary, interventions. 

There are limitations to consider with this recommendation. The definition and diagnostic criteria for 

preeclampsia have changed over time, and the cited review is not based on the current diagnostic criteria 

for preeclampsia.[193] It would be clinically useful to examine the predictive value of analytes for fetal 

growth restriction, which may necessitate early birth. This study did not review other complications 

associated with elevated MSAFP, such as stillbirth or premature labor.[193] 

As this is a Not reviewed, Amended recommendation, the Work Group did not systematically review 

evidence related to this recommendation. Based on the assessment of the quality of the evidence put 

forth in the 2009 Pregnancy CPG, including a peer-reviewed publication of a scientific study [191] and 

publications from other organizations,[139,192] the Work Group determined the confidence in the quality 

of the evidence was moderate in support of a qualified obstetric provider evaluating and counseling 

pregnant women with persistent unexplained elevations of MSAFP. The publications from other 

organizations that were included in the evidence base for the 2009 CPG [139,192] have been 

updated.[140,194,195] Other support for this recommendation stemmed from the benefits slightly 

outweighing the harms.

More research is needed to identify the role of serum analytes in a time when non-invasive prenatal 

screening is replacing serum analyte use for aneuploidy screening. Whether serum analytes have a role in 

risk prediction with respect to pregnancy complications, rather than being used for aneuploidy screening, 

needs to be determined. Finally, the specific combination and appropriate gestational age to examine 

serum analytes in not known. 
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Recommendations 

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)

Discussion 

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 shown no 

improvement in outcomes for either mother or baby.[196,197] 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.[198] In a woman at low risk for preterm 

delivery presenting with preterm contractions, a negative test may inform the decision to use or avoid 

tocolytics and corticosteroids.[197] 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. 

Other methods of screening for preterm delivery addressed in the 2009 VA/DoD Pregnancy CPG included 

cervical length. One large RCT examined the difference in rates of low birth weight, delivery at less than 37 

weeks gestation, and premature rupture of membranes between women who received routine cervical 

examinations and women who did not. It found no statistically significant difference between groups.[199] 

Recent research, identified outside of the systematic evidence review, also found that routine cervical 

length screening for the general population was not effective in predicting preterm birth.[200] 

As these are Not reviewed, Amended recommendations, the Work Group did not systematically review 

evidence related to these recommendations. Based on the assessment of the quality of the evidence put 

forth in the 2009 Pregnancy CPG, including peer-reviewed publications [196-198,201-203] and one 

publication from another organization,[204] the Work Group determined confidence in the quality of 

the evidence for both recommendations was moderate. One publication from another organization that 

was included in the evidence base for the 2009 CPG [204] has been updated and is consistent with the 

current recommendations.[205]. Recent research, identified outside of the systematic evidence review, 

has found that fetal fibronectin testing in asymptomatic women provided no benefit.[200,206] While 

testing was not found to be clinically harmful, it was associated with increased resource use.[206] The 

Work Group developed the strong recommendation against testing in asymptomatic women due to the 

absence of benefit coupled with the non-negligible cost of widespread testing. In the symptomatic subpopulation, acknowledging that there is very limited potential benefit for women treated in a large 

cross-section of treatment facilities, the Work Group valued the modest benefit in terms of treatment 

and transfer decision-making over the costs of the test for women treated at those select smaller 

facilities who might benefit. When testing is judiciously applied to those circumstances, the result may 
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likely alter management. The timeframe of 24 to 34 6/7 weeks gestation was chosen because it 

represents the period between viability and the point at which particular inventions (e.g., steroid 

treatment, tocolytics) would be considered. The lower limit of the gestational age testing, which may 

prompt intervention, should be individualized at each treatment facility, based on the threshold of 

viability established jointly by the neonatal intensive care unit and obstetric service.

D. Special Considerations

a. High Risk for Preeclampsia

Recommendation

17. For 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)

Discussion

Roberge et al. (2016), through an SR and meta-analysis of RCTs, compared the effect of daily aspirin or 

placebo during pregnancy.[207] The study, which included 45 RCTs totaling 20,909 pregnant women 

taking 60-150 mg of aspirin 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. 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. 

The Block-Abraham et al. (2014) prospective cohort study found that, for some of the women at an 

increased risk of developing preeclampsia, the risk may not be significant after a stepwise logistic 

regression, partially due to confounding issues (e.g., DM, hypertension, prior preeclampsia and 

obesity).[208] Some populations respond better. According to Gan et al. (2016), taking low dose aspirin 

decreased risk of preeclampsia in both subgroups studied, East Asians and non-East Asians; however, this 

study did not provide clinically significant information regarding other subpopulations.[209] The Work 

Group notes the USPSTF recommends low dose aspirin for prevention of preeclampsia in women with risk 

factors such as history of preeclampsia, multiple gestation, chronic hypertension, or DM.[210] 

As this is a Reviewed, New-added recommendation, the Work Group systematically reviewed evidence 

related to this recommendation in the evidence review conducted as part of this guideline 

update.[208,209] The Work Group determined the confidence in the quality of the evidence was high in 

support of low dose aspirin therapy for prevention of preeclampsia in women at risk. Other support for 

this recommendation stemmed from the benefits of this recommendation outweighing the harms. The 

benefits of taking low dose aspirin outweigh the harms of potential placental abruption, postpartum 

hemorrhage, or fetal harms such as intracranial bleeding and congenital anomalies. Aspirin in 81 mg 

strength is widely available in the U.S. over-the-counter or on the VA and DoD formularies. While the 

dosage and timing of initiation of low-dose aspirin varied across studies, the benefits of taking low dose 

aspirin outweighed the harms consistently across dosages and timing of initiation. Further research is 
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indicated for populations with the highest risk of developing preeclampsia. Additional studies examining 

any long-term effects of fetal exposure to low dose aspirin therapy are needed. 

b. High Risk for Preterm Delivery

Recommendation

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)

Discussion

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.[211-

213] 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.

One RCT (Deeks et al., 2011) found that using a U.S. Food and Drug Administration (FDA) approved 

formulation of 17 alpha-hydroxyprogesterone caproate intramuscularly (the formulation used in the study 

was MakenaTM) significantly reduced preterm delivery at 37, 35, and 32 weeks gestation in singleton 

pregnancies (not studied in women with multiple gestations). Preterm delivery rates were lower with 

treatment than with placebo. The benefit of the treatment in reducing the risk of preterm birth was 

observed in spontaneous deliveries regardless of maternal race. Furthermore, this study indicated a 

significantly lower rate of adverse neonatal outcomes such as necrotizing enterocolitis, need for 

supplemental oxygen, birth weight of <2500 g, and intraventricular hemorrhage among infants of women 

who received 17 alpha-hydroxyprogesterone caproate than among infants of placebo recipients.[214] 17 

alpha-hydroxyprogesterone caproate-exposed neonates showed no evidence of detrimental effect in a 

two to five year follow-up. 17 alpha-hydroxyprogesterone caproate is, at the time of publication, available 

on VA and DoD formularies. Further research may concentrate on following 17 alpha-hydroxyprogesterone 

caproate-exposed neonates beyond five years for evidence of detrimental effects. 

As this is a Not reviewed, Amended recommendation, the Work Group did not systematically review 

evidence related to this recommendation. Based on the assessment of the quality of the evidence put 

forth in the 2009 Pregnancy CPG, including peer-reviewed publications [211-213] and a publication from 

another organization,[204] the Work Group determined confidence in the quality of the evidence was 

moderate in support of antenatal progesterone therapy for women with a history of preterm delivery who 

are at risk for subsequent preterm delivery. One publication from another organization that was included 

in the evidence base for the 2009 CPG [204] has been updated.[205] The support for the strength of this 

recommendation is based on the significant benefits related to reducing morbidity and mortality that this 

treatment has for the developing fetus which clearly outweigh any potential harm. No evidence of 

detrimental effects between birth and five years of age has been found when the fetus was exposed to 

prenatal progesterone.
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c. Over 44 Years of Age

Recommendation

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) 

Discussion

The number of women over the age of 35 having children has increased significantly in the past few 

decades.[215] Advanced maternal age has been associated with higher rates of late-term 

stillbirths.[216] 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.[217] In addition to the adverse 

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

likely to become pregnant again. Alternative methods of management of pregnancy in women ages >35 

has often been suggested.[218] 

Chaudhary and Contag (2017) found that only mothers over the age of 44 had reduced prenatal mortality 

risk with immediate delivery at 38 weeks gestation.[219] This moderate quality evidence formed the basis 

for this recommendation. This retrospective cohort study of over 16 million pregnancies found that 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. Authors note 

that there was a low relative risk of death or complication from immediate delivery at 38 for all mothers. 

However, the reduction in stillbirth rates only occur in mothers over 44 years. Given the great benefit of 

avoiding stillbirth, the Work Group decided that a recommendation for immediate delivery at 38 weeks 

was warranted for women over 44 years. 

A second study only examined women between 35 and 44 years of age. Walker et al. (2016) completed an 

RCT of primigravid mothers 35 to 44 years of age.[220] The primary aim of the study was to determine if 

planned birth or induction of labor at 39 weeks reduced the risk of neonatal death. This study provided

high quality evidence that induction at 39 weeks did not reduce cesarean deliveries rates in primigravid 

women ages 35-44, and moderate quality evidence that it did not reduce maternal complications or 

neonatal outcomes.[220] Given that outcomes are similar in this group, patient preference and values 

should be considered when developing delivery plans for primigravid women aged 35-44 with 

uncomplicated pregnancies. Patient involvement in decisions about the method of delivery is considered 

best practice for all pregnancies and was a theme that emerged during the patient focus group (see 

Patient Focus Group Methods and Findings).

Increased financial costs for monitoring and medical interventions associated with planned induction are 

outweighed by reducing the highly negative impact of stillbirth. There may be an increase in late-term 

respiratory complications, although this was not demonstrated in an identified study.[220] Induction 

needs to be weighed against patient preferences, healthcare costs, and maternal outcomes. Counseling 

women of advanced maternal age on their risk of stillbirth is important as the trend of advancing age for 

first and subsequent pregnancies continues.[221] 
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As this is a Reviewed, New-added recommendation, the Work Group systematically reviewed evidence 

related to this recommendation in the evidence review conducted as part of this guideline 

update.[219,220] The Work Group determined the confidence in the quality of the evidence was moderate 

in support of planned delivery in women over the age of 44. There is moderate evidence available to 

support delivering women greater than 44 years of age at 38 weeks. One retrospective study of moderate 

quality (Chaudhary and Contag, 2017) found a clear benefit for women over 44 to be delivered at 38 

weeks.[219] Our selection criteria also identified one RCT, rated as “Good” per USPSTF criteria, that

evaluated women between ages 35-44 planned induction.[220] Findings did not support early induction 

between the ages of 35-44. The Work Group acknowledges that additional evidence that both supports 

and contradicts planned induction at advanced maternal ages exists, but was not included in this evidence 

review. These mixed results did not meet the inclusion criteria for the systematic review conducted for this 

CPG update. Thus, the Work Group decided upon a “Weak for” recommendation for planned deliveries for 

women greater than 44 years at 38 weeks.

Further research is recommended to understand the mechanism behind unexplained fetal death in 

women of advanced maternal age, and to determine the maternal age cut-off that optimizes neonatal 

outcomes while minimizing maternal risk.

d. History of Bariatric Surgery

Recommendations 

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)

Discussion

The prevalence of obesity has doubled from 1980 to 2008 and some women are becoming pregnant after 

bariatric surgery.[222] As noted in the VA/DoD Obesity CPG,16 many non-surgical treatments for obesity 

are available; however, obese patients are often unable to achieve substantial weight loss. Bariatric 

surgery has been proven to be an effective treatment for obesity. However, the impact of bariatric surgery 

on pregnancy has not been well studied. 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.

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. In the systematic evidence review conducted 

for this guideline update, interventions considered for women who have undergone bariatric surgery 

 

16 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/
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included nutritional screening, nutritional medicine referrals, nutritional management, and additional 

micronutrient supplementation.

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

deficiencies, most commonly vitamin B12, folate, iron, and calcium, and need for nutritional 

supplementation where indicated. The evidence supporting this recommendation was determined to be of 

low quality due to small sample sizes.[223,224] In addition to size limitations, there was also significant 

non-compliance with prescribed supplement regimens and heterogeneous bariatric surgery types with 

some having restrictive versus malabsorptive procedures.[223] There are minimal risks and potential 

benefits to evaluation and supplementation for vitamin B12, folate, iron, and calcium. Additional 

limitations to the studies reviewed include vague description of supplementation regimens used.[223] 

According to the VA/DoD Obesity CPG, the risk for nutritional deficiencies may vary depending on type of 

surgery performed. 17 The VA/DoD Obesity CPG states, “Specifically after Roux-en-Y gastric bypass, several

nutritional deficiencies are common and supplementation at higher than the usual recommended daily

dose may be required. Typical doses of elemental calcium are 1200-1200 mg daily, preferably as calcium

citrate which is better absorbed in the absence of gastric acid. The optimal dose of vitamin B12 is not

known. While all forms of delivery have been shown to be effective, poor absorption is common and 

sublingual or intramuscular injection may be required. Iron deficiency is common and typically all

patients receive prophylactic therapy in conjunction with vitamin C to enhance absorption.”

In studies reviewed, there were no serious adverse events related to evaluation and supplementation. 

There may be potential benefits that are greater for neonatal outcomes, but study sample sizes did not 

provide power to demonstrate. 

As these are Reviewed, New-replaced recommendations, the Work Group systematically reviewed 

evidence related to these recommendation in the evidence review conducted as part of this guideline 

update.[223,224] The Work Group determined confidence in the quality of the evidence was low (due to 

small sample sizes and vague reporting regarding supplementation regimens used) in support of 

evaluation for nutritional deficiencies and nutritional supplementation where indicated for women who 

have had bariatric surgery (Recommendation 20). The potential for improvement in neonatal outcomes

with evaluation outweighed the potential harm of evaluation, as no serious adverse events were shown in 

the studies. 

For pregnant women who have had prior bariatric surgery, the Work Group determined that there was 

insufficient evidence identified in the systematic review conducted for this CPG update to recommend for 

or against the routine supplementation of vitamins A, D, E, or K (Recommendation 21). The quality of 

evidence was very low.[223,224] When considering whether to monitor or supplement with vitamins A, D, 

E, or K, there is no evidence to support the ideal amount or route of supplementation or frequency.

According to the National Institutes of Health, women who might be pregnant should not take high doses 

of vitamin A supplements due to risks of potential birth defects.[225] 

 

17 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/
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Recommendations

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)

Discussion

There is limited research related to the nutritional management of the post-operative bariatric patient and 

of the patient with nutritional risk factors who is pregnant. The systematic evidence review conducted for 

the update of this CPG identified no evidence-based standardized practices. The VA/DoD Obesity CPG18

suggests that an “...integrated lifestyle program for the patient should be in place, both prior to and after 

the surgical procedure, to provide ongoing guidance and support.” Additionally, the VA/DoD Obesity CPG 

goes on to state that lifelong medical surveillance should be established for these patients to evaluate 

behavioral and nutritional status changes. One prospective study found that laparoscopic adjustable 

gastric banding prior to pregnancy was safe for both mother and newborn.[226] Another prospective 

study compared the pregnancy outcomes of women who underwent laparoscopic adjustable gastric 

banding prior to pregnancy to the pregnancy outcomes of women in the general community and obese 

women. The outcomes of pregnant women who underweight laparoscopic adjustable gastric banding 

were similar to women in the general community, rather than to obese women.[227] 

Pregnant women who have undergone bariatric surgery should be evaluated by a surgeon with bariatric 

expertise as early as possible during the pregnancy period. Pregnant women may require evaluation for 

needed adjustment of the gastric band if appropriate weight gain is not developing or if there is potential 

band slippage. Pregnancies after laparoscopic gastric banding can result in appropriate maternal and fetal 

weight gain.[226] Pregnant women may require assessment for weight management complications, such 

as inadequate weight gain or excessive weight loss, behavioral evaluation, and/or nutritional deficiencies. 

Appointments with general/bariatric surgeons may not be feasible at all locations and, even when 

available, limitations include that pregnant women may have to travel for multiple appointments, or see a 

different provider than the surgeon who performed the surgery. In these cases, the risk must be assessed 

against the benefit of this consultation. 

Pregnant women who have undergone bariatric surgery should establish (or re-establish) care with an RDN

to evaluate for adequate nutritional intake and potential nutritional deficiencies. Post-bariatric surgery 

nutritional deficiencies can be avoided with adequate dietary intake but can be readily addressed and 

treated when appropriately identified.[228] It is important to note that the VA/DoD Obesity CPG18 states:

“While evidence to support absolute contraindications for bariatric surgery is lacking, expert consensus 

states that women who are pregnant or who are considering pregnancy in the next 18-24 months should 

not be considered candidates for bariatric surgery.”[229] 

As this is a Reviewed, Amended recommendation, the Work Group systematically reviewed the evidence 

identified in the evidence review conducted for this CPG update and considered the assessment of the 

evidence put forth in the 2009 CPG, which included one publication from another organization.[230] They 

determined the evidence was of very low quality due to limited evidence and small sample size. However, 

 

18 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/ 
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the potential benefits of avoiding complications outweigh the little potential harm and burden to the 

patient and provider of being screened. Thus, the strength of this recommendation was determined to be 

“Weak for.”
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Appendix A: Evidence Review Methodology

A. Developing the Scope and Key Questions

The CPG Champions, along with the Work Group, were tasked with identifying KQs to guide the SR of the 

literature on pregnancy. These questions, which were developed in consultation with the Lewin team, 

addressed clinical topics of the highest priority for the VA and DoD populations. The KQs follow the 

population, intervention, comparison, outcome, timing and setting (PICOTS) framework for evidence 

questions, as established by the Agency for Healthcare Research and Quality (AHRQ). Table A-1 provides a 

brief overview of the PICOTS typology.

Table A-1. PICOTS [231] 

P 

Patients, 

Population, 

or Problem

A description of the patients of interest. It includes the condition(s), populations or subpopulations, disease severity or stage, co-occurring conditions, and other patient 

characteristics or demographics.

I Intervention 

or Exposure

Refers to the specific treatments or approaches used with the patient or population. It 

includes doses, frequency, methods of administering treatments, etc.

C Comparison

Describes the interventions or care that is being compared with the intervention(s) of interest 

described above. It includes alternatives such as placebo, drugs, surgery, lifestyle changes, 

standard of care, etc.

O Outcome Describes the specific results of interest. Outcomes can include short, intermediate, and longterm outcomes, or specific results such as quality of life, complications, mortality, morbidity, etc.

(T) Timing, if 

applicable

Describes the duration of time that is of interest for the particular patient intervention and 

outcome, benefit, or harm to occur (or not occur).

(S) Setting, if

applicable

Describes the setting or context of interest. Setting can be a location (such as primary, 

specialty, or inpatient care).

The Champions, Work Group, and evidence review team carried out several iterations of this process, each 

time narrowing the scope of the CPG and the literature review by prioritizing the topics of interest. Due to 

resource constraints, all developed KQs were not able to be included in the systematic evidence review.

Thus, the Champions and Work Group determined which questions were of highest priority, and those 

were included in the review. Table A-2 contains the final set of KQs used to guide the SR for this CPG. 

a. Population(s)

• Pregnant women 18 years or older treated in any VA/DoD primary care setting

b. Interventions 

• Key Question 1

 One-hour GTT 

 Two-hour GTT 

 Three-hour GTT 

 Hemoglobin A1c

 Fasting blood sugar 
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• Key Question 2

 Characteristics present 

• Key Question 3

In women with a history of bariatric surgery:

 Nutritional screening

 Nutritional medicine referral

 Nutritional management

 Additional micronutrient supplementation 

• Key Question 4

Aneuploidy screening in women presenting for initial prenatal care:

 Maternal serum screening

 Non-invasive prenatal screening/testing

 Ultrasound

 Amniocentesis (gold standard)

• Key Question 5

Routine VA/DoD screening methods:

 Depression: PHQ-9 

 Alcohol Use Disorder: AUDIT-C 

 Biological (e.g., toxicological screens)

• Key Question 6

 First trimester ultrasound

• Key Question 7

 Breastfeeding education delivered by provider

 Prior history of breastfeeding success or failure

 Breast examination

 Prior history of breast surgery or augmentation

 Nipple protrusion

 Tagged nipples

 Other physiological characteristics of the breast

 Presence of depressive symptoms

 Return to work
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• Key Question 8

 Exercise programs (e.g., aerobic exercise, yoga)

• Key Question 9 

Presence of: 

 Preeclampsia

 Eclampsia

 GDM 

 Gestational hypertension

• Key Question 10

 Antepartum surveillance

 Planned delivery

c. Comparators

• Key Question 1

 One-hour GTT followed by a three-hour GTT 

• Key Question 2

 Characteristics absent 

• Key Question 3

 Standard patient management

• Key Question 4

 Interventions (listed in above section b. Interventions) compared to each other

• Key Question 5

In pregnant and early (≤6 weeks) postpartum women: Perinatal-specific validated “Gold-standard” 

screens:

 Depression

♦ EPDS, EPDS-7, and the EPDS-2 

♦ Postpartum Depression Screening Scale (PDSS)

 Substance use disorders:

♦ T-ACE (Tolerance, Annoyed, Cut down, Eye-opener) 

♦ TWEAK (Tolerance, Worried, Eye-opener, Amnesia,[K] Cut-down)

♦ NET (Normal drinker, Eye-opener, Tolerance)

 4P’s Plus©
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• Key Question 6

 Date of LMP

• Key Question 7

 Usual care (e.g., no education, no history obtained, no breast examination, not 

returning to work)

• Key Question 8

 Different programs

 No exercise 

• Key Question 9 

 No presence of complications

• Key Question 10

 Expectant management (watchful waiting)

d. Outcomes

• Key Question 1

 Diagnosis of GDM

 Sensitivity, specificity, clinical utility, positive predictive value, negative predictive value 

• Key Question 2

 Preeclampsia

 Preeclampsia necessitating preterm delivery

 Recurrence of preeclampsia in woman with history of preeclampsia 

• Key Question 3

 Fetal growth

 Term delivery versus medically indicated preterm delivery

 Mode of delivery

 Maternal nutrition status

 Hyperemesis gravidarum

 Neonatal hypoglycemia 

 GDM 

 Macrosomia 

 Shoulder dystocia

• Key Question 4

 Sensitivity and specificity
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 Positive and negative predictive value

 Cost

 Rates of uptake of amniocentesis

 Impact on patient decision making (including toxic knowledge, decision to continue or 

terminate pregnancy, decision regarding delivery method) 

 Counseling

 Other clinical impact

• Key Question 5

Identification of:

 Depression

 Use of alcohol

 Anxiety 

 Other psychiatric disorders

• Key Question 6

 Accuracy 

 Avoidance of obstetrical complications (e.g., neonatal intensive care unit admission, 

induced labor, giving prenatal steroids)

 Reduction in unnecessary obstetrical interventions

• Key Question 7

Breastfeeding outcomes:

 Breastfeeding initiation and exclusive breastfeeding for four months

 Continuation of breastfeeding for 12 months

 Number of postnatal consultations for breastfeeding

• Key Question 8

 Maternal outcomes (e.g., overall health, excess weight gain, weight retention/failure to 

lose weight as expected after delivery, postpartum recovery, depression, anxiety, 

measures of general sense of well-being, GDM, mode of delivery)

 Fetal outcomes (e.g., large or small for gestational age)

• Key Question 9 

Adverse lifetime health outcomes: 

 PTSD

 DM 

 CVD and/or CVD markers including laboratory markers: cardiac calcium score (Agatston 

score), C-reactive protein, endothelial intimal thickness
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 Autoimmune disorders (rheumatoid arthritis, lupus, fibromyalgia)

• Key Question 10

 Stillbirth

 Maternal complication

♦ Gestational hypertension

♦ Preeclampsia

♦ Mode of delivery

♦ Macrosomia 

 Fetal outcomes 

♦ Fetal growth restrictions 

♦ Neonatal intensive care unit admission

B. Conducting the Systematic Review

Based on the decisions made by the Champions and Work Group members regarding the scope, the KQs, 

and the PICOTS statements, the Lewin Team produced a systematic review protocol prior to conducting 

the review. The protocol was reviewed and approved by the Champions and Work Group members. It

described in detail the final set of KQs, the methodology to be used during the systematic review process, 

and the inclusion/exclusion criteria to be applied to each potential study, including, but not limited to, 

study type, sample size, and PICOTS criteria. 

Extensive literature searches identified 6,863 citations potentially addressing the KQs of interest to this 

evidence review. Of those, 3,276 were excluded upon title review for clearly not meeting inclusion criteria 

(e.g., not pertinent to the topic, not published in English, published prior to study inclusion publication 

date, or not a full-length article). Overall, 3,554 abstracts were reviewed with 2,677 of those being 

excluded for the following reasons: not an SR or an accepted study design (see the General Criteria for 

Inclusion in Systematic Review and Key Question Specific Criteria), did not address a KQ of interest to this 

review, did not report on an outcome of interest, or published outside cut-off publication dates. A total of 

910 full-length articles were reviewed. Of those, 601 were excluded at a first pass review for the following: 

not addressing a KQ of interest, not enrolling the population of interest, not meeting inclusion criteria for 

study design, not meeting inclusion criteria for any KQ, or being a duplicate. A total of 309 full-length 

articles were thought to address one or more KQs and were further reviewed. Of these, 239 were 

ultimately excluded. Reasons for their exclusion are presented in Figure A-1 below. 

Overall, 70 studies addressed one or more of the KQs and were considered as evidence in this review. 

Table A-2 indicates the number of studies that addressed each of the questions. 
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Figure A-1. Study Flow Diagram

, 

239 Citations Excluded at 2nd Pass KQ Level

65 Wrong study design or does not address a KQ

7 Wrong study population

93 SR superseded by more comprehensive review or 

relevant studies included in report; study already 

included in an SR

50 No outcomes of interest or comparator not of 

interest

5 Outside region of interest

5 Enrolled too few patients

14 Other (e.g. duplicate, not a clinical trial or SR)

3,276 Citations Excluded at the Title Level

Citations excluded at this level were off-topic, not 

published in English, or published prior to

inclusion date

6,863 Citations Identified by Searches

3,587 Abstracts 

Reviewed

2,677 Citations Excluded at the Abstract Level

Citations excluded at this level were not SR or CS, 

clearly did not address a KQ, did not report on an 

outcome of interest, or were outside cutoff 

publication dates

309 Articles 

Reviewed

70 Included Studies

601 Citations Excluded at 1st Pass Full Article Level

255 Wrong study design or does not address a KQ

11 Wrong study population or population not 

reported separately

35 Superseded by more comprehensive review or 

relevant studies included in report

73 Comparator or outcome not of interest

155 Outside region of interest

54 Enrolled too few patients

11 Not a full publication or not published in 

English

7 Other (e.g. duplicate, not a clinical trial or SR)

910 Full-length Articles Reviewed

Abbreviations: CS: clinical study; KQ: key question; SR: systematic review
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Table A-2. Evidence Base for KQs 

Question 

Number Question

Number of Studies & Type of 

Studies

1 What is the optimal way to screen for and diagnose GDM in 

pregnant women a) with or b) without preexisting risk factors?

1 RCT

2 prospective cohort studies

2 What are the characteristics of patients who are more likely to 

respond to aspirin for prevention of preeclampsia?

2 SRs

2 secondary analyses of RCT data

1 nested case-control study

3 What nutritional interventions improve outcomes for pregnant 

women who have had bariatric surgery?

2 prospective cohort studies

4 What are the comparative accuracy, clinical utility, and cost of 

methods of aneuploidy screening? 

6 SRs

11 diagnostic accuracy 

1 non-RCT 

5 In pregnant and early postpartum women, are perinatal survey 

screens for psychiatric and substance use disorders as effective or 

more effective as routine screening methods or toxicological 

screens?

1 RCT

1 cohort study

6 Does first trimester ultrasound to confirm gestational age improve

obstetrical outcomes?

3 prospective cohort studies 

2 retrospective cohort studies

7 In pregnant women, what factors or interventions impact 

probability of initiating and continuing breastfeeding?

4 SRs

1 non-RCT

2 cohort studies

8 In pregnant women, what is the impact of exercise frequency, 

type, and intensity on maternal and fetal outcomes?

8 SRs

2 RCTs

9 In women following childbirth, does presence of pregnancyrelated complications predict the risk of adverse lifetime health 

outcomes?

3 SRs

10 cohort studies 

2 case-control studies

10 In pregnant women, at what maternal age and what gestational 

age should antepartum surveillance and planned delivery be 

considered?

1 RCT

2 retrospective cohort studies

Total Evidence Base 70 studies

Abbreviations: GDM: gestational diabetes mellitus; RCT: randomized controlled trial; SR: systematic review

a. General Criteria for Inclusion in Systematic Review

• Studies or SRs published on or after January 1, 2008 to February 4, 2017, except as noted below.

If multiple SRs addressed a KQ, the most recent and/or comprehensive review was included. SRs

were supplemented with clinical studies published subsequent to the SR.

 An updated search for KQ 9 was done on March 1, 2017, in which pregnancy and 

synonyms were not included in the search, as it was determined that the original search 

parameters were too restrictive. We identified one additional systematic review that 

addressed KQ 9, which was published later than the original date cut-off, and was added 

to the evidence base for that question.

 At the face-to-face meeting it was determined that retrospective studies potentially were 

needed to more fully address KQ 10. Updated searches were conducted up to May 18, 
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2017. We identified two additional studies that addressed KQ 10 that were added to the 

evidence base for that question.

• English language publication.

• Publication must have been a full study or SR; abstracts alone were not included. Similarly,

letters, editorials, and other publications that were not full-length clinical studies were not

accepted as evidence.

• Intervention studies needed to have a treatment or management style and have been a

prospective, RCT with an independent control group, unless otherwise noted (see Key Question

Specific Criteria below). Crossover trials were not included. The ideal diagnostic study compares

clinical outcomes after diagnostic technology evaluation versus clinical evaluation, or compares

clinical outcomes linked to different diagnostic technologies. However, non-comparative

diagnostic studies that reported a change in management strategy or patient outcomes (e.g.,

evidence of organic based disease patterns) were included.

• Study must have enrolled at least 20 patients (10 per study group) unless otherwise noted (see

Key Question Specific Criteria below).

• Study must have reported on an outcome of interest. Studies must have enrolled a patient

population in which at least 80% of patients were pregnant at the time of enrollment. If the

percentage was less than 80%, then data must have been reported separately for the patient

subgroup.

b. Key Question Specific Criteria

• For KQs 1, 4, and 6, acceptable study designs included SRs of acceptable study designs, RCTs,

and diagnostic cohort studies.

• For KQ 4, studies examining cost effectiveness must have been prospective comparisons or

cohort studies looking at diagnostic performance of one or more tests and a cost effectiveness

analysis. Modeling studies using previously published or retrospectively analyzed data (e.g.,

from patient registries and/or Medicare payer reports) or studies using published diagnostic

performance data to simulate the cost effectiveness of testing in a hypothetical cohort (i.e., no

actual patient data incorporated into the model) were excluded.

• For KQs 2, 7, and 9, acceptable study designs included SRs of acceptable study designs, RCTs (if

available), large prospective (100 patients per arm) and retrospective (200 patients per arm)

cohort studies. Cohort studies must have performed multivariate analyses of the prognostic

factors of interest on patient outcomes.

• For KQ2, studies looking at incidental use of aspirin were not included.

• For KQs 3, 8, and 10 acceptable study designs included SRs of RCTs and/or individual RCTs.

• For KQ 5, SRs of acceptable study designs and RCTs were prioritized. If insufficient evidence was

available to address the KQ, then large prospective (100 patients per arm) and retrospective

(200 patients per arm) cohort studies were considered. Cohort studies must have performed

multivariate analyses of the prognostic factors of interest on patient outcomes.
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• If insufficient evidence was available to address a KQ, then large prospective (100 patients per

arm) non-RCTs were considered. Retrospective analyses were not included.

c. Literature Search Strategy

Information regarding the bibliographic databases, date limits, and platform/provider can be found in 

Table A-3, below. Additional information on the search strategies, including topic-specific search terms and 

search strategies can be found in Appendix F. 

Table A-3. Bibliographic Database Information

Name Date Limits* Platform/Provider

Cochrane Database of Systematic Reviews 

(Cochrane Reviews) January 1, 2008 to February 4, 2017 Wiley

Cochrane Central Register of Controlled Trials January 1, 2008 to February 4, 2017 Wiley

Database of Abstracts of Reviews of Effects January 1, 2008 to February 4, 2017 Wiley

EMBASE (Excerpta Medica) January 1, 2008 to February 4, 2017 Elsevier

Health Technology Assessment Database 

(HTA) January 1, 2008 to February 4, 2017 Wiley

MEDLINE/PreMEDLINE January 1, 2008 to February 4, 2017 Elsevier

PsycINFO January 1, 2008 to February 4, 2017 OvidSP

PubMed (In-process and Publisher records) January 1, 2008 to February 4, 2017 National Library of 

Medicine

*Bibliographic searches were initiated on December 27, 2016 and continued through February 4, 2017.

C. Convening the Face-to-face Meeting

In consultation with the COR, the Champions, and the Work Group, the Lewin Team convened a three 

and one half day face-to-face meeting of the CPG Champions and Work Group members on May 16 – 

19, 2017. These experts were gathered to develop and draft the clinical recommendations for an update 

to the 2009 Pregnancy CPG. Lewin presented findings from the evidence review in order to facilitate and 

inform the process. 

Under the direction of the Champions, the Work Group members were charged with interpreting the 

results of the evidence review and were asked to categorize and carry forward recommendations from the 

2009 Pregnancy CPG, modifying the recommendations as necessary. The members also developed new 

clinical practice recommendations not presented in the 2009 Pregnancy CPG based on the 2017 evidence 

review. The subject matter experts were divided into two smaller subgroups at this meeting. 

As the Work Group members drafted clinical practice recommendations, they also assigned a grade for 

each recommendation based on a modified GRADE and USPSTF methodology. Each recommendation was 

graded by assessing the quality of the overall evidence base, the associated benefits and harms, the 

variation in values and preferences, and other implications of the recommendation. 

In addition to developing recommendations during the face-to-face meeting, the Work Group members 

also revised the 2009 Pregnancy CPG algorithms to reflect the new and amended recommendations. They 

discussed the available evidence as well as changes in clinical practice since 2009, as necessary, to update 

the algorithms.
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D. Grading Recommendations

This CPG uses the GRADE methodology 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: [232] 

• Balance of desirable and undesirable outcomes 

• Confidence in the quality of the evidence 

• Values and preferences

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

 Resource use

 Equity

 Acceptability

 Feasibility

 Subgroup considerations

The following sections further describe each domain. 

Balance of desirable and undesirable outcomes refers to the size of anticipated benefits (e.g., increased 

longevity, reduction in morbid event, resolution of symptoms, improved quality of life, decreased 

resource use) and harms (e.g., decreased longevity, immediate serious complications, adverse event, 

impaired quality of life, increased resource use, inconvenience/hassle) relative to each other. This 

domain is based on the understanding that the majority of clinicians will offer patients therapeutic or 

preventive measures as long as the advantages of the intervention exceed the risks and adverse effects. 

The certainty or uncertainty of the clinician about the risk-benefit balance will greatly influence the 

strength of the recommendation.

Some of the discussion questions that fall under this domain include:

• Given the best estimate of typical values and preferences, are you confident that the benefits 

outweigh the harms and burden or vice versa?

• Are the desirable anticipated effects large?

• Are the undesirable anticipated effects small?

• Are the desirable effects large relative to undesirable effects?

Confidence in the quality of the evidence reflects the quality of the evidence base and the certainty in 

that evidence. This second domain reflects the methodological quality of the studies for each outcome 

variable. In general, the strength of recommendation follows the level of evidence, but not always, as 

other domains may increase or decrease the strength. The evidence review used for the development of 

recommendations, conducted by ECRI, assessed the confidence in the quality of the evidence base using 

GRADE methodology and assigned a rating of “High,” “Moderate,” “Low,” or “Very Low.”
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The elements that go into the confidence in the quality of the evidence include: 

• Is there high or moderate quality evidence that answers this question?

• What is the overall certainty of this evidence?

Values and preferences is an overarching term that includes patients’ perspectives, beliefs, expectations, 

and goals for health and life. More precisely, it refers to the processes that individuals use in considering 

the potential benefits, harms, costs, limitations, and inconvenience of the therapeutic or preventive 

measures in relation to one another. For some, the term “values” has the closest connotation to these 

processes. For others, the connotation of “preferences” best captures the notion of choice. In general, 

values and preferences increase the strength of the recommendation when there is high concordance and 

decrease it when there is great variability. In a situation in which the balance of benefits and risks are 

uncertain, eliciting the values and preferences of patients and empowering them and their surrogates to 

make decisions consistent with their goals of care becomes even more important. A recommendation can 

be described as having “similar values,” “some variation,” or “large variation” in typical values and 

preferences between patients and the larger populations of interest.

Some of the discussion questions that fall under the purview of values and preferences include:

• Are you confident about the typical values and preferences and are they similar across the 

target population?

• What are the patient’s values and preferences? 

• Are the assumed or identified relative values similar across the target population?

Other implications consider the practicality of the recommendation, including resource use, equity, 

acceptability, feasibility and subgroup considerations. Resource use is related to the uncertainty around 

the cost-effectiveness of a therapeutic or preventive measure. For example statin use in the frail elderly 

and others with multiple co-occurring conditions may not be effective and, depending on the societal 

benchmark for willingness to pay, may not be a good use of resources. Equity, acceptability, feasibility, and 

subgroup considerations require similar judgments around the practically of the recommendation.

The framework below (Table A-4) was used by the Work Group to guide discussions on each domain.
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Table A-4. GRADE Evidence to Recommendation Framework

Decision Domain Questions to Consider Judgment

Balance of desirable 

and undesirable 

outcomes

 Given the best estimate of typical values and 

preferences, are you confident that the 

benefits outweigh the harms and burden or 

vice versa?

 Are the desirable anticipated effects large?

 Are the undesirable anticipated effects small?

 Are the desirable effects large relative to 

undesirable effects?

 Benefits outweigh harms/burden

 Benefits slightly outweigh 

harms/ burden

 Benefits and harms/burden are 

balanced

 Harms/burden slightly outweigh 

benefits

 Harms/burden outweigh benefits

Confidence in the 

quality of the 

evidence

 Is there high or moderate quality evidence that 

answers this question?

 What is the overall certainty of this evidence?

 High

 Moderate

 Low

 Very low

Values and 

preferences

 Are you confident about the typical values and 

preferences and are they similar across the 

target population?

 What are the patient’s values and 

preferences? 

 Are the assumed or identified relative values 

similar across the target population?

 Similar values

 Some variation

 Large variation

Other implications 

(e.g., resource use, 

equity, 

acceptability, 

feasibility, 

subgroup 

considerations)

 Are the resources worth the expected net 

benefit from the recommendation?

 What are the costs per resource unit?

 Is this intervention generally available?

 Is this intervention and its effects worth 

withdrawing or not allocating resources from 

other interventions?

 Is there lots of variability in resource 

requirements across settings?

 Various considerations

The strength of a recommendation is defined as the extent to which one can be confident that the 

desirable effects of an intervention outweigh its undesirable effects and is based on the framework above, 

which combines the four domains.[233] GRADE methodology does not allow for recommendations to be

made based on expert opinion alone. While strong recommendations are usually based on high or 

moderate confidence in the estimates of effect (quality of the evidence) there may be instances where 

strong recommendations are warranted even when the quality of evidence is low.[232] In these types of 

instances where the balance of desirable and undesirable outcomes and values and preferences played 

large roles in determining the strength of a recommendation, this is explained in the discussion section for 

the recommendation.

The GRADE of a recommendation is based on the following elements:

• Four decision domains used to determine the strength and direction (described above)

• Relative strength (Strong or Weak)

• Direction (For or Against)
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The relative strength of the recommendation is based on a binary scale, “Strong” or “Weak.” A strong 

recommendation indicates that the Work Group is highly confident that desirable outcomes outweigh 

undesirable outcomes. If the Work Group is less confident of the balance between desirable and 

undesirable outcomes, they present a weak recommendation. 

Similarly, a recommendation for a therapy or preventive measure indicates that the desirable 

consequences outweigh the undesirable consequences. A recommendation against a therapy or 

preventive measure indicates that the undesirable consequences outweigh the desirable consequences.

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 ...”)

Note that weak (For or Against) recommendations may also be termed “Conditional,” “Discretionary,” or 

“Qualified.” Recommendations may be conditional based upon patient values and preferences, the 

resources available, or the setting in which the intervention will be implemented. Recommendations may 

be at the discretion of the patient and clinician or they may be qualified with an explanation about the 

issues that would lead decisions to vary.

E. Recommendation Categorization

a. Recommendation Categories and Definitions

A set of recommendation categories was adapted from those used by NICE.[27,28] 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 A-5. 
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Table A-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) [27] and Garcia et al. (2014) [28] 

Abbreviation: CPG: clinical practice guideline

b. Categorizing Recommendations with an Updated Review of the Evidence

Recommendations were first categorized by whether or not they were based on an updated review of the 

evidence. If evidence had been reviewed, recommendations were categorized as “New-added,” “Newreplaced,” “Not changed,” “Amended,” or “Deleted.” 

“Reviewed, New-added” recommendations were original, new recommendations that were not in the 

2009 Pregnancy CPG. “Reviewed, New-replaced” recommendations were in the previous version of the 

guideline, but were modified to align with the updated review of the evidence. These recommendations 

could have also included clinically significant changes to the previous version. Recommendations 

categorized as “Reviewed, Not changed” were carried forward from the previous version of the CPG 

unchanged. 

To maintain consistency between 2009 recommendations, which were developed using the USPSTF 

methodology, and 2018 recommendations, which were developed using the GRADE methodology, it was 

necessary to modify the 2009 recommendations to include verbiage to signify the strength of the 

recommendation (e.g., “We recommend,” “We suggest”). Because the 2009 recommendations inherently 

needed to be modified at least slightly to include this language, the “Not changed” category was not used. 

For recommendations carried forward to the updated CPG with review of the evidence and slightly 

modified wording, the “Reviewed, Amended” recommendation category was used. This allowed for the 

wording of the recommendation to reflect GRADE methodology as well as for any other non-substantive 

(i.e., not clinically meaningful) language changes deemed necessary. The evidence used to support these 
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recommendations was carried forward from the previous version of the CPG and/or was identified in the 

evidence review for the update. 

Recommendations could have also been designated “Reviewed, Deleted.” These were recommendations 

from the previous version of the CPG that were not brought forward to the updated guideline after review 

of the evidence. This occurred if the evidence supporting the recommendations was out of date, to the 

extent that there was no longer any basis to recommend a particular course of care and/or new evidence 

suggests a shift in care, rendering recommendations in the previous version of the guideline obsolete.

c. Categorizing Recommendations without an Updated Review of the Evidence

There were also cases in which it was necessary to carry forward recommendations from the previous 

version of the CPG without an updated SR of the evidence. Due to time and budget constraints, the 

update of the Pregnancy CPG could not review all available evidence on management of pregnancy, but 

instead focused its KQs on areas of new or updated scientific research or areas that were not previously 

covered in the CPG. 

For areas of research that have not changed, and for which recommendations made in the previous 

version of the guideline were still relevant, recommendations could have been carried forward to the 

updated guideline without an updated SR of the evidence. The support for these recommendations in the 

updated CPG was thus also carried forward from the previous version of the CPG. These recommendations 

were categorized as “Not reviewed.” If evidence had not been reviewed, recommendations could have 

been categorized as “Not changed,” “Amended,” or “Deleted.” 

“Not reviewed, Not changed” recommendations refer to recommendations from the previous version of 

the Pregnancy CPG that were carried forward unchanged to the updated version. The category of “Not 

reviewed, Amended” was used to designate recommendations which were modified from the 2009 

Pregnancy with the updated GRADE language, as explained above. 

Recommendations could also have been categorized as “Not reviewed, Deleted” if they were 

determined to be out of scope. A recommendation was out of scope if it pertained to a topic (e.g., 

population, care setting, treatment, and condition) outside of the scope for the updated CPG as defined 

by the Work Group. 

The categories for the recommendations included in the 2018 version of the guideline are noted in the 

Recommendations. The categories for the recommendations from the 2009 Pregnancy CPG are noted in 

Appendix D. 

F. Drafting and Submitting the Final Clinical Practice Guideline

Following the face-to-face meeting, the Champions and Work Group members were given writing 

assignments to craft discussion sections to support each of the new recommendations and/or to update

discussion sections from the 2009 Pregnancy CPG to support the amended “carried forward” 

recommendations. The Work Group also considered tables, appendices, and other sections from the 2009 

Pregnancy CPG for inclusion in the update. During this time, the Champions and Work Group also made 

additional revisions to the algorithms, as necessary. 
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After developing the initial draft of the updated CPG, an iterative review process was used to solicit 

feedback on and make revisions to the CPG. Once they were developed, the first two drafts of the CPG 

were posted on a wiki website for a period of 14-20 business days for internal review and comment by the 

Work Group. All feedback submitted during each review period was reviewed and discussed by the Work 

Group and appropriate revisions were made to the CPG. 

Draft 3 of the CPG was made available for peer review and comment. This process is described in the 

section titled Peer Review Process. After revisions were made based on the feedback received during the 

peer review and comment period, the Champions presented the CPG to the EBPWG for their approval.

Changes were made based on feedback from the EBPWG and the guideline was finalized. 

The Work Group also produced a set of guideline toolkit materials which included a provider summary, 

pocket card, and patient summary. The final 2018 Pregnancy CPG was submitted to the EBPWG in 

March 2018. 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

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Appendix B: Patient Focus Group Methods and Findings

A. Methods

As part of the effort to update this CPG, the VA and DoD Leadership held two patient focus groups. The 

first was held on December 1, 2016 at the Washington DC VA Medical Center in Washington, DC. The 

second was held on February 2, 2017 at Malcolm Grow Medical Clinics and Surgery Center at Joint Base 

Andrews, MD. The aim of the focus groups was to further understand and incorporate the perspective 

of patients covered and/or receiving their care through the VA and/or DoD healthcare systems during 

their pregnancy and perinatal period, as patients are most affected by the recommendations put forth in 

the CPG. The focus groups delved into the patients’ perspectives on a set of topics related to their 

pregnancy care, including their priorities, challenges they have experienced, and the information they 

received regarding their pregnancy care, as well as the impacts of their pregnancy and their pregnancy 

care on their lives. 

Participants for the focus group were recruited by VA and DoD Leadership as well as by the Pregnancy CPG 

Champions. Patient focus group participants were not designed to be a representative sample of VA and 

DoD pregnant patients. However, recruitment focused on eliciting a range of perspectives likely to be 

relevant and informative in the guideline development process. Patients were not incentivized for their 

participation or reimbursed for travel expenses.

The Pregnancy CPG Champions and Work Group, with support from Lewin, developed a set of questions to 

help guide the focus group. The focus group facilitator led the discussion using the previously prepared 

questions as a general guide to elicit the most important information from the patients regarding their 

experiences and views about their treatment and overall care. Given the limited time and the range of 

interests of the focus group participants, not all of the listed questions were addressed. 

Four patients participated in the focus groups with two patients participating in each session. Two

participants had received care through the DoD healthcare system and two received care from community 

providers through the VA. 

B. Patient Focus Group Findings 

a. Recognize the importance of a support network throughout pregnancy, including 

as a trusted source of information specific to a patient’s unique pregnancy 

experience (e.g., as a first-time parent or Active Duty Service Member)

• Patients, particularly those receiving care through the DoD, seemed to lack a network that they 

could trust and rely upon for support, leaving them with a sense of isolation. They indicated that 

support groups organized through the VA and DoD could be helpful in providing this network.

• Patients desired more information about their unique experience of being pregnant, e.g., as a 

first-time parent or an Active Duty Service Member of the military, that could help them feel 

prepared throughout their pregnancy and when their baby arrived.

• Patients valued the support they received from their families, friends, and colleagues during 

their pregnancy, and advised offering more formal support groups to enhance the patients’ 

networks and share information.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 80 of 147

b. Provide information regarding general pregnancy care to the patient in a timely 

manner and in a way that is responsive to the patients’ goals, values, and 

preferences

• Patients desired reliable sources of information related to pregnancy, including information 

regarding their health and the health of their babies during pregnancy. 

• Patients appreciated variation in the comprehensiveness, portability, and connectivity of 

multiple sources of information that could be useful in different circumstances (e.g., handbook, 

mobile application, and pamphlet). 

• Patients appreciated the information they received regarding general pregnancy care, but noted 

that more information was needed regarding their specific situations (e.g., as a Veteran, Active 

Duty Service Member, or beneficiary of a Service Member). 

c. Provide comprehensive, understandable information regarding covered services 

to the patient and help the patient navigate that information and answer 

questions as needed

• Patients desired formal, reliable and easy to navigate sources of information related to 

pregnancy, including comprehensive information regarding their covered services. 

• Patients noted limitations and inconsistency in VA/DoD coverage of pregnancy-related services 

and supplies based on the information available to them and encouraged considering 

expansions in this coverage.

d. Recognize the importance of the relationship between the patient and her

provider and care team and the necessity for the patient to have consistency in 

this relationship and her access to care

• Patients valued open and trusting relationships with familiar pregnancy healthcare providers 

and care teams.

• Patients valued the consistency in their relationships with their providers throughout their 

pregnancies and deliveries. 

• Patients recognized the importance of a discussion regarding contingency plans in the event of a 

sudden or precipitous delivery necessitating an unfamiliar provider and wanted reassurance that 

their care would still be carried out smoothly. 

e. Ensure that the family is involved in the pregnancy in accordance with patient 

preferences and recognize the differences among families in structure and 

composition

• Patients expressed the desire for their family to be involved in their pregnancy and for their 

providers and care teams to support their preferences regarding involving family members in 

their care. 

• Patients noted differences in structure and composition across families and the need for VA and 

DoD healthcare services to recognize and appreciate these differences as they deliver care for 

pregnant women and their families. 
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March 2018 Page 81 of 147

f. Ensure that patients know the options for pediatric healthcare and day care early 

in their pregnancy and provide information so that they can feel secure in their 

planning

• Patients did not receive adequate formal information regarding pediatric care for their 

newborns or how to identify healthcare providers for their children.

• Patients were not aware of the day care options available and advised that this topic be 

broached early in a patient’s pregnancy to allow adequate time to plan. 

g. Improve communication and information sharing between VA and community 

providers to ensure patients receive the individualized care they need without 

undue stress

• Patients stressed the need for improved communication and information sharing (e.g., billing 

information, medical records) between the VA and the community providers under the Choice 

Program.

• Patients valued their care from the community providers, but indicated that community 

providers need to be better educated regarding military culture and potential exposures that 

could impact the health of Veterans and military personnel. 

• Patients recognized the importance of their geographic location in receiving their care as 

planned during their delivery and valued the planning and communication needed to adjust the 

birth plan as needed during their deliveries.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 82 of 147

Appendix C: Evidence Table

Recommendation 2009 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation

Category 4

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

acceptable alternative to individual provider appointments.

A [74,75] 

Additional References: 

[76]

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.

A [77-82,84,85,87] 

Additional References: 

[83,86] 

Strong for Reviewed,

Amended

3. We suggest that women with uncomplicated pregnancies

continue a standard work schedule throughout their pregnancy.

B [88-92]

Additional References:

[93]

Weak for Not reviewed, 

Amended

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

taken starting one month before conception and continued

throughout pregnancy and breastfeeding.

A, A [57,58,94,97,98,101-103] 

Additional References: 

[59,60,95,96,99,100] 

Strong for Not reviewed, 

Amended

1 The 2009 VA/DoD Pregnancy CPG used the USPSTF evidence grading system (http://www.uspreventiveservicestaskforce.org). Inclusion of more than one 2009 Grade indicates that 

more than one 2009 CPG recommendation is covered under the 2018 recommendation. The strength of recommendations were rated as follows: A- a strong recommendation 

that the clinicians provide the intervention to eligible patients; B- a recommendation that clinicians provide (the service) to eligible patients; C- no recommendation for or against 

the routine provision of the intervention is made; D- recommendation is made against routinely providing the intervention; I- the conclusion is that the evidence is insufficient to 

recommend for or against routinely providing the intervention. “Not applicable” indicates that the 2018 Pregnancy CPG recommendation was a new recommendation, and 

therefore does not have an associated 2009 Grade. 2 The first set of references listed in each row in the evidence column constitutes the evidence base for the recommendation. To be included in the evidence base for a 

recommendation, a reference needed to be identified through the 2017 evidence review or included in the evidence base for the 2009 VA/DoD Pregnancy CPG. The second set of 

references in the evidence column (called “Additional References”) includes references that provide additional information related to the recommendation, but which were not 

systematically identified through a literature review. These references were not included in the evidence base for the recommendation and therefore did not influence the 

strength and direction of the recommendation. 3 Refer to the Grading Recommendations section for more information on how the strength of the recommendation was determined using GRADE methodology. 4 Refer to the Recommendation Categorization section for more information on the description of the categorization process and the definition of each category.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 83 of 147

Recommendation 2009 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation

Category4

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

).

A, A, B, B, C, C [118-128]

Additional References: 

[104-117,129] 

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. 

B, B [132] 

Additional References: 

[130,131] 

Strong for Reviewed, Newreplaced

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?”

B, B, C, B, B [136-138] 

Additional References:

[133-135]

Strong for Reviewed, Newreplaced

8. We suggest making prenatal diagnostic testing for aneuploidy 

available to all pregnant women.

B, B, I [139,143-148] 

Additional References:

[140-142] 

Weak for Reviewed, Newreplaced

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.

I, B [149-154] Strong for Reviewed, Newreplaced

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.

B, B, C, B, C, C [155-157,160-162,234-

237] 

Additional References:

[158,159,163,164] 

Weak for Reviewed, Newreplaced

 

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 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 84 of 147

Recommendation 2009 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation

Category4

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. 

B, B, B, B [165,166] Strong for Reviewed, Newreplaced

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.

A, C [171-174] 

Additional References:

[167-170] 

Strong for Reviewed, 

Amended

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.

Not applicable [175-189] 

Additional References:

[190] 

Strong for Reviewed, Newadded

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.

B [139,191,192] 

Additional References:

[140,193-195]

Weak for Not reviewed, 

Amended

15. We recommend against routine screening for preterm delivery

using the fetal fibronectin test in asymptomatic women.

D [196-198,201-204]

Additional References:

[199,200,205,206] 

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.

B [196-198,201-204] 

Additional References:

[199,200,205,206]

Strong for Not reviewed, 

Amended

17. For women at risk of preeclampsia, we recommend low dose

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

weeks gestation.

Not applicable [207-209]

Additional References:

[210] 

Strong for Reviewed, Newadded
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 85 of 147

Recommendation 2009 Grade1 Evidence2

Strength of 

Recommendation3

Recommendation

Category4

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.

B, B, C [204,211-213]

Additional References: 

[205,214] 

Strong for Not reviewed, 

Amended

19. We suggest offering women greater than 44 years of age planned 

delivery at 38 weeks gestational age to reduce the risk of 

stillbirth.

Not applicable [219,220] 

Additional References:

[215-218,221] 

Weak for Reviewed, Newadded

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).

C [223,224]

Additional References:

[222,225]

Weak for Reviewed, Newreplaced

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.

C [223,224] 

Additional References:

[222,225] 

N/A Reviewed, Newreplaced

22. We suggest that pregnant women with a history of gastric bypass 

surgery be evaluated by a surgeon with bariatric expertise.

C [230]

Additional References:

[61,226-229]

Weak for Reviewed, 

Amended
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March 2018 Page 86 of 147

Appendix D: 2009 Recommendation Categorization Table 

2009 Location1

2009 Recommendation Text2

2009 

Grade3

Recommendation 

Category4

2018

Recommendation5

SectionNumberPage

A-0 1 12 Goal-oriented prenatal care system can be delivered to all pregnant women. B Not reviewed, Deleted

A-0 2 12 Education should be a central component of prenatal care for all pregnant women. B Not reviewed, Deleted

A-0 3 12 Group model of prenatal care, such as the Centering Pregnancy® model, is an acceptable 

alternative to individual provider appointments.

A Not reviewed, Amended Recommendation 1

A-2 1 14 Initial assessment by nurse may include the following actions:

a. Assure the patient completes the Self-Questionnaire (see Appendix B - Screening Items for 

Self-Administered Questionnaire – First Visit)

b. Review the patient’s completed Self-Questionnaire for issues requiring immediate evaluation 

or intervention (see Appendix B - Screening Items for Self-Administered Questionnaire – 

First Visit)

c. Obtain initial prenatal lab tests to be reviewed and documented at the following visit 

d. Consult with an advanced prenatal care provider regarding advice or instruction to the 

patient if there are immediate needs (see Table-1)

e. Arrange immediate referral to advanced prenatal care for follow-up in cases needing shortterm assessment or intervention (see Table-1)

f. Provide brief information about options for screening for fetal chromosomal abnormalities 

and arrange for counseling (See I-36)

g. Arrange follow-up with the appropriate provider at 10-12 weeks.

None Not reviewed, Deleted

A-3 1 16 At the first provider visit, a complete medical history and physical examination (including 

thyroid, breast and pelvic examination) should be obtained. Information from the previous 

visit(s) and laboratory studies should be reviewed and significant problems/risks should be 

assessed.

None Not reviewed, Deleted

1 The first three columns indicate the location of each recommendation within the 2009 VA/DoD Pregnancy CPG.

2 The 2009 Recommendation Text column contains the wording of each recommendation from the 2009 VA/DoD Pregnancy CPG. 

3 The 2009 VA/DoD Pregnancy CPG used the U.S. Preventive Services Task Force (USPSTF) evidence grading system: http://www.uspreventiveservicestaskforce.org. The strength of 

recommendations were rated as follows: A- a strong recommendation that the clinicians provide the intervention to eligible patients; B- a recommendation that clinicians provide 

(the service) to eligible patients; C- no recommendation for or against the routine provision of the intervention is made; D- recommendation is made against routinely providing 

the intervention; I- the conclusion is that the evidence is insufficient to recommend for or against routinely providing the intervention. “None” indicates there was no grade 

assigned to the recommendation in the 2009 Pregnancy CPG. 4 The Recommendation Category column indicates the way in which each 2009 Pregnancy CPG recommendation was updated. 5 For recommendations that were carried forward to the 2018 VA/DoD Pregnancy CPG, this column indicates the new recommendation(s) to which they correspond.
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 87 of 147

2009 Location

2009 Recommendation Text

2009 

Grade

Recommendation 

Category

2018

SectionNumberPage

Recommendation 2 3 4 5

1

A-3 2 16 At the first provider visit, the provider should outline an individualized plan of prenatal care that 

includes guideline-based routine prenatal care and consultation with advanced prenatal care 

providers or other medical specialty care services if needed.

None Not reviewed, Deleted

A-3 3 16 The following are conditions not addressed by this guideline that will require supplemental care 

that might be best provided by routine or advanced obstetric care providers and/or behavioral 

health providers depending on the individual circumstances and local conditions: 

‒ Current mental illness requiring medical therapy

‒ Substance use disorders

‒ Eating disorders.

None Not reviewed, Deleted

A-3 4 16 The following are among conditions that require supplemental prenatal care or consultation 

with or referral to an advanced prenatal care provider (Table 2):

a. General

‒ Body mass index (BMI) <16.5 or >30

‒ Age (<16 or > 34 years at delivery)

‒ At risk for diabetes

b. Infections:

‒ Hepatitis B or C (see I-11)

‒ Human Immunodeficiency virus (HIV)

‒ Syphilis (positive RPR)

‒ Cytomegalovirus (CMV)

‒ Toxoplasmosis

‒ Primary Herpes

‒ Rubella

‒ Parvovirus

‒ Positive gonorrhea (see I-29)

‒ Positive Chlamydia (see I-30)

‒ Genital herpes (see I-32)

‒ Recurrent urinary tract infections/stones

None Reviewed, Deleted
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March 2018 Page 88 of 147

2009 Location1

2009 Recommendation Text2

2009 

Grade3

2018

Recommendation5

SectionNumberPage

A-3

cont.

4 16 c. Pre-existing medical conditions:

‒ Abnormal pap smear (see I-31)

‒ Controlled hypothyroidism

‒ Previous gastric bypass/bariatric surgery (see I-28)

‒ Mild depression (I- 21 & 34)

‒ Cardiovascular disease

‒ High blood pressure

‒ Familial hyperlipidemia

‒ Pregestational diabetes

‒ Kidney disease (including pyelonephritis)

‒ Inflammatory bowel disease

‒ Bronchio pulmonary disease including asthma

‒ Autoimmune diseases including Anticardiolipin Antibody Syndrome, and Systemic Lupus 

Erythematosis

‒ Thromboembolic disease, current or historical

‒ Cancer

‒ Seizure disorders

‒ Hematologic disorders (including anemia, thrombocytopenia)

‒ Genetic disease with known effect on pregnancy

d. Obstetric conditions:

‒ Vaginal bleeding

‒ Isoimmunization

‒ Placenta previa—symptomatic or present beyond 28 weeks

‒ Placental abruption

‒ At risk for preterm birth (see A-4)

‒ Prior cesarean section (see I-39)

‒ Previous uterine or cervical surgery

‒ Intrauterine fetal demise

‒ Preterm labor

‒ Preterm ruptured membranes

‒ Recurrent pregnancy loss

‒ Suspected or documented fetal growth abnormalities (intrauterine growth restriction 

[IUGR] or macrosomia)

‒ Abnormalities of amniotic fluid including oligohydramnios, polyhydramnios

‒ Fetal anomaly(s)

‒ Multiple gestation

‒ Surgical condition during pregnancy (e.g., appendectomy, ovarian cystectomy, cerclage)

Category4

Recommendation 
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March 2018 Page 89 of 147

2009 Location1

2009 Recommendation Text2

2009 

Grade3

Recommendation 

Category4

2018

Recommendation5

SectionNumberPage

A-4 1 21 Women should be assessed for preterm birth risk as early as possible in the pregnancy in order 

to optimize maternal and newborn outcomes.

None Not reviewed, Deleted

A-4 2 21 Screening for preterm birth risk factors should continue up to 37 weeks estimated gestational 

age.

None Not reviewed, Deleted

A-4 3 21 Women at increased risk but meeting the criteria for normal surveillance should have the risk 

factor(s) documented in the medical record to increase awareness of the risk but may continue 

to be followed in accordance with the routine management of the pregnancy guideline.

None Not reviewed, Deleted

A-4 4 21 Routine care providers should consult with an advanced prenatal care provider whenever a 

woman meets the criteria for increased surveillance for preterm birth.

None Not reviewed, Deleted

A-4 5 21 Women requiring increased surveillance should be considered for ancillary studies and other 

additional intervention. Progesterone supplementation should be considered in these women 

(see A-4).

None Not reviewed, Deleted

A-4 6 21 Routine screening of fetal fibronectin (fFN) in asymptomatic or low-risk women is not 

recommended (see I-52). fFN testing in symptomatic or high-risk women between 24 and 34 

6/7 weeks’ gestation may be useful in guiding management.

None Not reviewed, Deleted

A-4 7 21 The measurement of cervical length by transvaginal ultrasound may be useful in some patients 

requiring increased surveillance for preterm labor. Sonographic cervical length measurement is 

not recommended as a routine screening or prediction tool in women only requiring normal 

surveillance.

None Not reviewed, Deleted

A-4 8 21 The determination of salivary estriol levels, bacterial vaginosis screening and home uterine 

activity monitoring are not recommended as a means to predict preterm birth.

None Not reviewed, Deleted

A-4 9 21 It is reasonable to offer antenatal progesterone therapy to women at high-risk for preterm 

delivery and who meet the generally accepted inclusion criteria.

B Not reviewed, Amended Recommendation 18

A-4 10 21 Progesterone may be administered intramuscularly on a weekly basis or intravaginally on a daily 

basis.

B Not reviewed, Amended Recommendation 18

A-4 11 21 Progesterone therapy should only be initiated after consultation with an advanced prenatal 

care provider (obstetrician or maternal-fetal medicine specialist).

C Not reviewed, Amended Recommendation 18
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2009 Location1

2009 Recommendation Text2

2009 

Grade3

Recommendation 

Category4

2018

Recommendation5

SectionNumberPage

A-7 1 24 The following should be included in the postpartum visit: 

‒ Pelvic and breast examinations. [B] 

‒ Cervical smear should be completed as indicated by cervical cancer screening guidelines 

(see I-31). [A] 

‒ Initiate or continue the HPV vaccine series for women age < 26 years (see I-50). [C] 

‒ Screening for postpartum depression (see I-21). [B] 

‒ Screening for domestic violence (see I-20). [B] 

‒ Diabetes testing for patients with pregnancies complicated by gestational diabetes. The twohour 75g oral glucose tolerance test (GTT) is recommended but a fasting glucose can also be 

done. [B] 

‒ Education about contraception, infant feeding method, sexual activity, weight, exercise and 

the woman’s assessment of her adaptation to motherhood. Pre-existing or chronic medical 

conditions should be addressed with referral for appropriate follow-up as indicated. [I]

B, A, C, 

B, B, B, I

Not reviewed, Deleted

I-1 1 29 Recommend measuring blood pressure of all pregnant women at each prenatal visit, following 

the guidelines of the National High Blood Pressure Education Program and the VA/DoD Clinical 

Practice Guidelines for Hypertension.

B Not reviewed, Deleted

I-1 2 29 Women diagnosed with hypertension during pregnancy should be managed by, or in 

consultation with, an advanced prenatal care provider.

C Not reviewed, Deleted

I-1 3 29 Korotkoff 5 sound (disappearance of sound) will be used to determine the diastolic pressure. C Not reviewed, Deleted

I-2 1 30 Recommend offering breastfeeding education to all pregnant women during the first visit with 

the provider.

B Reviewed, NewreplacedRecommendation 7 

I-2 2 30 Recommend asking pregnant women, “What do you know about breastfeeding?” rather than, 

“Do you plan on breast or bottle feeding?” to provide an open opportunity for education.

B Reviewed, NewreplacedRecommendation 7

I-2 3 30 Recommend continuing education throughout pregnancy for those pregnant women who 

express a desire to breastfeed or for those who are still undecided on feeding method.

C Reviewed, NewreplacedRecommendation 7

I-2 4 30 Recommend including family/significant others in breastfeeding education. B Reviewed, NewreplacedRecommendation 7

I-3 1 31 Strongly recommend all healthy, pregnant women perform regular mild to moderate exercise 

sessions, three or more times per week.

A Reviewed, Amended Recommendation 2 

I-3 2 31 Recommend individualized exercise programs for all pregnant women, based on their prepregnancy activity level.I Reviewed, Deleted

I-3 3 31 Recommend against high-altitude (>10,000 feet) activities, scuba diving, and contact sports 

during pregnancy.

I Reviewed, Deleted

I-4 1 33 Recommend immunizing all pregnant women for influenza during the epidemic season. B Not reviewed, Deleted
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

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2009 Location1

2009 Recommendation Text2

2009 

Grade3

Recommendation 

Category4

2018

Recommendation5

SectionNumberPage

I-5 1 33 Strongly recommend routine screening for tobacco use in pregnancy at the initial prenatal visit. 

For patients who smoke, recommend assessment of smoking status at each subsequent 

prenatal visit.

A Not reviewed, Amended Recommendation 5 

I-5 2 33 If the screening is positive, cessation should be strongly recommended. A Not reviewed, Amended Recommendation 5 

I-5 3 33 There is insufficient data to recommend for or against pharmacologic therapy for tobacco 

cessation in pregnancy.

I Not reviewed, Deleted

I-6 1 34 Recommend routine screening for alcohol consumption using a standardized tool (refer to the 

VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders).

B Not reviewed, Amended Recommendation 5 

I-6 2 34 If the screening is positive, cessation should be strongly recommended. B Not reviewed, Amended Recommendation 5 

I-6 3 34 There is insufficient evidence regarding which cessation intervention tool is the most effective. I Not reviewed, Deleted

I-7 1 35 Recommend routine screening for illicit drug use using a self-report method. C Not reviewed, Amended Recommendation 5 

I-7 2 35 Recommend pregnant women identified as abusing drugs be offered treatment and receive 

care in consultation with or referral to an advanced prenatal care provider. (See also VA/DoD 

Clinical Practice Guideline for the Management of Substance Use Disorders.)

C Not reviewed, Amended Recommendation 5 

I-8 1 36 Recommend evaluation of maternal ABO and Rh blood type and blood antibody status at the 

initial prenatal visit.

B Not reviewed, Deleted

I-8 2 36 Pregnant women with positive antibody screens should be referred for consultation to assist 

with further management.

C Not reviewed, Deleted

I-8 3 36 There is insufficient evidence to recommend for or against routine repeat testing at 28 weeks' 

gestation.

I Not reviewed, Deleted

I-9 1 36 Recommend all pregnant women have a serum screen for rubella status at the initial prenatal 

visit.

B Not reviewed, Deleted

I-9 2 36 Recommend seronegative pregnant women be counseled to avoid exposure. B Not reviewed, Deleted

I-9 3 36 Recommend seronegative pregnant women be vaccinated in the immediate postpartum 

period.

B Not reviewed, Deleted

I-10 1 37 Recommend routine screening for varicella through history. B Not reviewed, Deleted

I-10 2 37 If negative/unsure history, obtain a varicella titer. B Not reviewed, Deleted

I-10 3 37 Recommend offering vaccination postpartum, if varicella is non-immune. B Not reviewed, Deleted

I-11 1 38 Recommend routine laboratory screening for hepatitis B surface antigen at the initial prenatal 

visit.

A Not reviewed, Deleted
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2009 Location1

2009 Recommendation Text2

2009 

Grade3

Recommendation 

Category4

2018

Recommendation5

SectionNumberPage

I-11 2 38 Repeat laboratory screening of pregnant women with identification of hepatitis risk factors 

during the pregnancy (e.g., healthcare worker, intravenous (IV) drug use, exposure to hepatitis, 

visit for evaluation or therapy for sexually transmitted infections, and new tattoos and blood 

transfusions).

C Not reviewed, Deleted

I-11 3 38 Vaccinate pregnant women with hepatitis risk factors who have not been previously vaccinated. B Not reviewed, Deleted

I-11 4 38 Women at risk for HBV infection in pregnancy should be counseled concerning additional 

methods to prevent HBV infection.

C Not reviewed, Deleted

I-12 1 39 Treat all infants born to hepatitis B positive mothers with Hepatitis B immunoglobulin and 

initiate hepatitis B vaccination within 12 hours of birth.

A Not reviewed, Deleted

I-12 2 39 Strongly consider treating infants born to women at high risk for hepatitis B who have not been 

vaccinated or whose infectious status is unknown.

B Not reviewed, Deleted

I-12 3 39 Consider treating women who have high copy numbers of HBV-DNA with lamivudine during the 

last month of pregnancy.

B Not reviewed, Deleted

I-12 4 39 Women with HBV infection should be taught, and encouraged to implement, strategies to 

decrease transmission to non-infected intimate contacts.

B Not reviewed, Deleted

I-13 1 40 Recommend routine screening for syphilis using serologic testing (i.e., RPR or Venereal Disease 

Research Laboratory [VDRL]) at the initial prenatal visit.

B Not reviewed, Deleted

I-13 2 40 Recommend a confirmatory test using a more specific treponemal assay (FTA-ABS, MHA-TP, 

HATTS) for pregnant women who test positive.

B Not reviewed, Deleted

I-13 3 41 Strongly recommend therapy with penicillin G antibiotic for pregnant women who have 

confirmed syphilis, as recommended by other sexually transmitted disease (STD) guidelines.

A Not reviewed, Deleted

I-13 4 41 Recommend appropriate medical and legal mandates follow-up and state/service branch 

reporting requirements for pregnant women screening positive.

I Not reviewed, Deleted

I-14 1 41 Strongly recommend screening for ASB at initial obstetrical visit via urine culture and sensitivity. A Not reviewed, Deleted

I-14 2 41 There is insufficient evidence to recommend for or against repeat screening throughout the 

remainder of pregnancy.

I Not reviewed, Deleted

I-14 3 41 Strongly recommend a three to seven-day course of appropriate antibiotics based on positive 

culture and sensitivity, and woman's history of medication allergies.

A Not reviewed, Deleted

I-14 4 41 There is insufficient evidence to recommend for or against a test of cure (TOC) after completion 

of antibiotic therapy, except in pregnant women with ASB-Group B Strep.

I Not reviewed, Deleted

I-15 1 43 All pregnant women from one or more high-risk groups should be screened for tuberculosis 

with a Mantoux test with purified protein derivative (PPD) soon after the pregnancy is 

diagnosed.

C Not reviewed, Deleted
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I-15 2 43 Pregnant women with a positive PPD with known conversion in the last two years and no 

clinical or X-ray evidence of disease should be treated with isoniazid (300 mg per day) starting 

after the first trimester and continuing for nine months.

C Not reviewed, Deleted

I-15 3 43 For pregnant women with a positive PPD whose time of conversion is unknown and who have 

no clinical or X-ray evidence of disease present, consider delaying therapy until after the 

pregnancy.

C Not reviewed, Deleted

I-15 4 43 Pregnant women with active tuberculosis should be treated with multi-drug therapy including 

isoniazid and rifampin, supplemented by ethambutol if isoniazid drug resistance is suspected.

C Not reviewed, Deleted

I-16 1 44 Strongly recommend routine testing for HIV infection at the initial prenatal visit. A Not reviewed, Deleted

I-16 2 44 Pregnant women who test positive for HIV should be referred for treatment and counseling. I Not reviewed, Deleted

I-16 3 44 Recommend retesting all high-risk pregnant women during the early third trimester and offer 

repeat testing for patients who refused the first test.

B Not reviewed, Deleted

I-17 1 44 Strongly recommend routine screening for Tdap booster status at the initial prenatal visit. A Not reviewed, Deleted

I-17 2 44 If there is no documentation of Td booster within the last 10 years:

a. Provide Tdap in the immediate postpartum period before discharge from the hospital or 

birthing center

b. May provide Tdap at an interval as short as two years since the most recent Td vaccine

c. Provide Td during pregnancy for tetanus and diphtheria protection when indicated, or defer 

the Td vaccine indicated during pregnancy to substitute Tdap vaccine in the immediate 

postpartum period if the woman is likely to have sufficient protection against tetanus and 

diphtheria.

A Not reviewed, Deleted

I-17 3 45 Td booster should be provided if indicated. There are no contraindications other than a 

previous severe reaction to Td vaccination, such as anaphylaxis, generalized uriticaria, or 

angioedema.

A Not reviewed, Deleted

I-17 4 45 If the pregnant woman is an immigrant and it is unclear that she ever received the primary 

vaccination series, she should be given a primary series with an initial dose, a second dose a 

month later, and a third dose 12 months later.

I Not reviewed, Deleted

I-18 1 46 All pregnant women should be screened for anemia during pregnancy with a hematocrit or 

hemoglobin measurement during the first visit.

C Not reviewed, Deleted

I-18 2 46 Pregnant women with anemia should be further evaluated to define the cause of the anemia 

and given nutrient supplementation if deficient (e.g. iron, B12 or Folate).

C Not reviewed, Deleted

I-18 3 46 Red blood cell transfusion should be considered for pregnant women with severe anemia. C Not reviewed, Deleted

I-18 4 46 Iron sucrose transfusion should be considered for pregnant women with iron deficiency anemia 

who fail to respond to oral iron supplementation after eliminating modifiable causes of 

malabsorption.

C Not reviewed, Deleted
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I-19 1 46 Carrier screening should be offered to individuals of African, Southeast Asian, and 

Mediterranean descent.

A Not reviewed, Deleted

I-19 2 46 A complete blood count and hemoglobin electrophoresis are the recommended tests to screen 

for hemoglobinopathies.

B Not reviewed, Deleted

I-20 1 47 Recommend routine screening for domestic abuse at the first visit, week 28, and the postpartum visit, using the following three simple/direct questions: 

‒ Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by 

someone?

‒ Since you've been pregnant, have you been hit, slapped, kicked, or otherwise physically hurt 

by someone?

‒ Within the last year, has anyone forced you to engage in sexual activities?

B Not reviewed, Deleted

I-20 2 47 There is insufficient evidence to recommend for or against specific interventions for identified 

domestic abuse in pregnancy.

I Not reviewed, Deleted

I-20 3 47 If the screening is positive, follow appropriate medical/legal mandates for reporting 

requirements for state/branch of service.

C Not reviewed, Deleted

I-21 1 49 Women should be screened for depression during their first contact with obstetric healthcare 

services, at week 28 and at the postpartum visit.

B Not reviewed, Amended Recommendation 6 

I-21 2 49 Depression screening should be performed using a standardized screening tool such as the 

Edinburgh Postnatal Depression Scale (EDPS) or the PHQ-2.

B Not reviewed, Amended Recommendation 6 

I-21 3 49 Women should be asked early in pregnancy if they have had any previous psychiatric illnesses, 

and if they had a past history of serious psychiatric disorder they should be referred for a 

psychiatric assessment during the antenatal period.

B Not reviewed, Deleted

I-22 1 51 Establish the gestational age-based estimated delivery date (EDD) prior to 20 weeks’ gestational 

age.

B Reviewed, NewreplacedRecommendation 11 

I-22 2 51 Various information and methods for dating a pregnancy may be available for consideration. 

EDD should be based on the most accurate information/method available for the individual 

pregnancy (see Table 4. Accuracy of Pregnancy Dating Information/Modalities (Prioritized List).

B Reviewed, NewreplacedRecommendation 11 

I-22 3 51 Gestational age permitting, first-trimester ultrasound should be used to establish the 

gestational age and EDD if there is any uncertainty regarding the EDD due to: a pelvic 

examination discrepancy (> +/- two weeks), an unknown or uncertain last menstrual period 

(LMP), or irregular menstrual cycles.

B Reviewed, NewreplacedRecommendation 11 

I-22 4 52 When a first-trimester dating ultrasound has not been previously performed a dating 

ultrasound at 16 to 22 weeks should be obtained. This examination can be combined with a 

basic screening anatomy ultrasound.

B Reviewed, NewreplacedRecommendation 11
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I-22 5 52 Situations with abnormal fetal biometric ratios (e.g., head / abdominal circumference [HC/AC], 

biparietal diameter / femur length [BPD/FL]) limit the accuracy of biometric measurements for 

pregnancy dating and may signal fetal anomalies or karyotype abnormalities. Such 

circumstances require individualized assessment by an advanced prenatal care provider to 

establish dating and recommend ongoing assessment(s) and management.

C Not reviewed, Deleted

I-22 6 52 When clinical decisions late in pregnancy necessitate gestational age information and the dates 

have not been established prior to the 29th week, fetal maturity may be assumed when one of 

the following criteria are met: 

a. 20 weeks of audible fetal heart tones by a non-electronic method

b. 30 weeks of audible fetal heart tones by an electronic method

c. 36 weeks from a positive pregnancy test in a reliable laboratory.

C Not reviewed, Deleted

I-23 1 53 Recommend assessing fetal heart tones at each prenatal visit, starting at 10 to 12 weeks. C Not reviewed, Deleted

I-24 1 54 Recommend measuring fundal height in all pregnant women at each visit during the second and 

third trimesters.

B Not reviewed, Deleted

I-24 2 54 There is insufficient evidence to recommend for or against measuring fundal height after 36 

weeks’ gestation.

I Not reviewed, Deleted

I-25 1 55 Recommend assessing and documenting body mass index (BMI) of all pregnant women at the 

initial visit.

B Not reviewed, Deleted

I-25 2 55 Pregnant women found to have a BMI <20 kg/m2 should be referred for nutrition counseling 

and considered at increased risk for fetal growth restriction.

B Not reviewed, Deleted

I-25 3 55 Recommend screening for inappropriate weight gain for all women at every visit during 

pregnancy.

C Not reviewed, Deleted

I-25 4 55 Pregnant women with inadequate weight gain at 28 weeks who are unresponsive to nutritional 

treatment need additional surveillance. Consider consultation /referral to advanced prenatal 

care provider.

C Not reviewed, Deleted

I-26 1 56 Multivitamin supplements should be taken one month preconceptually and should be 

continued through the first trimester.

C Not reviewed, Amended Recommendation 4

I-26 2 56 Pregnant women taking nutritional supplements for a medical condition should continue that 

supplementation throughout pregnancy (e.g., B-12 with pernicious anemia and folate with 

seizure disorders).

I Not reviewed, Deleted

I-26 3 56 Pregnant women on restrictive diets (vegetarians, bariatric surgery) should have nutrition 

consultation to customize vitamin supplementation regimen.

I Not reviewed, Deleted 

I-26 4 56 Folate supplements (400 mcg daily) should be taken one month preconceptually, continued 

through the first trimester and should be administered as part of the multivitamin 

supplementation.

A Not reviewed, Amended Recommendation 4 
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I-26 5 56 Women who have delivered a child with an open neural tube defect (NTD) should supplement 

their diets with 4 mg folate daily for at least one month prior to conception and through the 

first trimester to reduce the risk of recurrence.

A Not reviewed, Amended Recommendation 4 

I-26 6 56 Calcium supplementation may be considered to reduce the risk of preeclampsia in high-risk 

women and those with low baseline calcium intake.

A Not reviewed, Deleted

I-26 7 57 There is insufficient evidence to support the use of Omega 3 supplements in the prevention of 

preterm birth, preeclampsia, and low birth weight.

I Not reviewed, Deleted

I-26 8 57 Other dietary supplements should be used with caution and only after discussion with provider. I Not reviewed, Deleted

I-27 1 58 Recommend the following for obese pregnant women:

a. Provision of specific information concerning maternal and fetal risks of obesity

b. Consideration of screening for gestational diabetes mellitus (GDM) on presentation or in the 

first trimester and repeated screening later in pregnancy if results are initially negative

c. Assessment and possible supplementation of vitamin B12, folate, iron, and calcium for 

women who have undergone bariatric surgery

d. Anesthesia consultation before labor

e. Possible use of graduated compression stockings, hydration, and early mobilization during 

and after cesarean section

f. Continuation of nutrition counseling and exercise program after delivery, and consultation 

with weight loss specialists before attempting another pregnancy.

I Reviewed, Deleted

I-28 1 59 Women with a gastric band should be monitored by their general surgeons during pregnancy 

because adjustment of the band may be necessary.

C Reviewed, Amended Recommendation 22

I-28 2 59 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, and 

calcium).

C Reviewed, NewreplacedRecommendation 20

Recommendation 21 

I-28 3 59 Women who experience dumping syndrome should NOT be screened for gestational diabetes 

with a glucose load but rather with fasting and two-hour postprandial glucose values.

C Not reviewed, Amended Recommendation 33

I-29 1 60 Recommend screening for gonorrhea in all pregnant women. B Not reviewed, Deleted

I-29 2 60 Pregnant women with positive cultures should be treated with ceftriaxone, per the CDC 

guidelines.

B Not reviewed, Deleted

I-29 3 60 Pregnant women with positive screens for gonorrhea should be screened for other sexually 

transmitted diseases (STDs) and follow local mandatory reporting requirements.

I Not reviewed, Deleted

I-29 4 60 Recommend performing a test of cure (TOC) during pregnancy after completing antibiotic 

therapy. TOC in pregnant women, unlike non-pregnant women, is recommended due to risk of 

complications resulting from persistent or recurrent infections.

I Not reviewed, Deleted

I-29 5 60 Recommend counseling to decrease rate of reinfection. C Not reviewed, Deleted
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I-29 6 60 Recommend referring the partner for testing and treatment, as appropriate. C Not reviewed, Deleted

I-29 7 60 Infected pregnant women must abstain from intercourse pending TOC. C Not reviewed, Deleted

I-30 1 61 Recommend screening all pregnant women for Chlamydia trachomatis at the initial physical 

examination.

B Not reviewed, Deleted

I-30 2 61 Pregnant women with positive cultures should be treated with azithromycin or erythromycin, 

per the CDC guidelines.

A Not reviewed, Deleted

I-30 3 61 Pregnant women with positive screens for Chlamydia should be screened for other sexually 

transmitted diseases (STDs).

I Not reviewed, Deleted

I-30 4 61 Recommend performing a test of cure (TOC) during pregnancy after completing antibiotic 

therapy. TOC in pregnant women, unlike nonpregnant women, is recommended due to risk of 

complications resulting from persistent or recurrent infections.

C Not reviewed, Deleted

I-30 5 61 Recommend counseling to decrease rate of re-infection. C Not reviewed, Deleted

I-30 6 61 Recommend referring partner for testing and treatment, as appropriate. C Not reviewed, Deleted

I-30 7 61 Infected pregnant women must abstain from intercourse pending TOC. C Not reviewed, Deleted

I-31 1 62 Women current with routine screening for cervical cancer do not need to undergo additional 

testing. If the woman will come due for routine screening before the eight week postpartum 

visit, a screening test should be performed at the first prenatal visit.

B Not reviewed, Deleted

I-31 2 62 For women who do not receive cervical cancer screening antenatally, screening should be 

considered at the eight-week postpartum visit to ensure compliance with routine cervical 

cancer screening guidelines.

B Not reviewed, Deleted

I-31 3 62 Recommend performing cervical screening in pregnancy with a brush sampler and spatula. A Not reviewed, Deleted

I-31 4 62 Recommend women with abnormal cervical cytology during pregnancy be managed based on 

local algorithms, which may include repeat testing, observation, or colposcopy.

C Not reviewed, Deleted

I-32 1 63 Routine HSV culture-based screening of pregnant patients is not recommended. I Not reviewed, Deleted

I-32 2 63 Symptomatic patients, those who are seropositive, or seronegative patients who have infected 

partners require further testing and counseling.

B Not reviewed, Deleted

I-33 1 64 Information about cystic fibrosis (CF) should be provided to all couples. I Not reviewed, Deleted

I-33 2 64 For couples who desire screening at <18 weeks’ gestation, only one partner should initially be 

screened; if the screening is positive then the other partner should be screened.

I Not reviewed, Deleted

I-33 3 64 Cystic fibrosis carrier screening should be offered to all couples who desire it. Informed consent 

should be obtained prior to testing.

I Not reviewed, Amended Recommendation 9

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I-33 4 64 Either sequential (testing one partner first) or concurrent (testing both partners simultaneously) 

carrier screening for cystic fibrosis is appropriate. The latter option may be preferred if there 

are time constraints for decisions regarding prenatal diagnostic testing or termination of the 

affected pregnancy.

I Not reviewed, Deleted

I-33 5 64 Recommend genetic counseling for individuals with a family history of cystic fibrosis, or for 

individuals found to be carriers of two cystic fibrosis mutations who have not previously 

received a diagnosis of cystic fibrosis.

I Not reviewed, Deleted

I-34 1 65 When antenatal depression symptoms are mild to moderate, consider referring patients for 

non-pharmacological treatment, such as Interpersonal Therapy (IPT).

A Not reviewed, Deleted

I-34 2 65 When pharmacological treatment of depression is necessary during pregnancy, the potential 

risks of SSRI exposure during pregnancy should be balanced with the potential risks of 

untreated depression on the mother and fetus.

B Not reviewed, Deleted

I-34 3 65 Avoid paroxetine use during pregnancy when possible. Consider fetal echocardiography for 

women exposed to paroxetine during early pregnancy.

B Not reviewed, Deleted

I-34 4 65 Choice of medications should be based on the well-characterized reproductive safety profiles of 

the medication, while also considering the severity of the depressive disorder and the wishes of 

the pregnant patient.

C Not reviewed, Deleted

I-34 5 65 Multidisciplinary management of the pregnant patient with depression is recommended to the 

extent that it is possible. This may involve the patient’s obstetrician, behavioral healthcare 

provider, primary care physician, and pediatrician.

C Not reviewed, Deleted

I-35 1 67 Assessment of oral health and instruction on maintaining a high level of oral hygiene should be 

offered to all pregnant women during their initial prenatal assessment to promote oral health 

and the general health of the woman.

C Not reviewed, Deleted

I-35 2 67 Preventative dental treatment is safe and should be provided as early in pregnancy as possible. B Not reviewed, Deleted

I-35 3 67 Routine dental care, including x-rays and periodontal therapy, are effective and safe during 

pregnancy, and should be recommended.

B Not reviewed, Deleted

I-35 4 67 There is insufficient evidence to recommend the routine treatment of periodontal disease in 

order to alter the rates of preterm delivery (PTD), low birth weight (LBW) or fetal growth 

restriction.

I Not reviewed, Deleted

I-36 1 69 All pregnant women, regardless of age, should be offered a prenatal screening test for the most 

common clinically significant fetal anomalies as a routine part of prenatal care.

B Reviewed, NewreplacedRecommendation 9 

I-36 2 69 Women presenting for care at appropriate gestational ages should have aneuploidy screening 

and diagnostic options available to them that provide first-trimester results as well as strategies 

that provide second-trimester results. The specific first-trimester screening strategy made 

available by or in the institution must be decided prior to embarking upon that strategy.

B Reviewed, NewreplacedRecommendation 8 

Recommendation 9
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I-36 3 69 Initial limited and comprehensive prescreen/pretest counseling methods may include written or 

multimedia communication, one-on-one, or group counseling formats. Posttest and late entry 

counseling should be provided in an individualized one-on-one format.

B Not reviewed, Deleted

I-36 4 69 Screening programs should show respect for the needs and quality of life of the woman and her 

family. Counseling should be nondirective and should respect a woman’s choice to accept or to 

refuse any or all of the testing or options offered at any point in the process.

I Not reviewed, Deleted

I-36 5 69 The following modes of prenatal screening/diagnostic testing should be available for women 

receiving prenatal care in the DoD/VA: 

a. No test at all

b. Screening with results in first trimester

c. Screening with results in second trimester

d. Diagnostic/invasive test in first and second trimester.

B Reviewed, NewreplacedRecommendation 8

Recommendation 9

I-36 6 69 In order to make these screening and diagnostic options available, each institution providing 

prenatal care should provide locally or arrange for access to: genetic counseling, first- and 

second-trimester serum marker assessment, first-trimester nuchal translucency (NT) 

measurement, basic and comprehensive second-trimester 

ultrasound assessment, first-trimester chorionic villus sampling and second-trimester 

amniocentesis.

I Not reviewed, Deleted

I-36 7 69 All women considered high-risk, due to maternal age, personal or family history, or the result of 

a previous test, should be offered the choice of a first- or second-trimester screening strategy 

and the choice of first- or second trimester diagnostic testing including appropriate 

comprehensive pre- and post-test genetic counseling.

I Reviewed, NewreplacedRecommendation 8

Recommendation 9 

I-36 8 69 A comprehensive ultrasound may be offered as a primary or follow-on screening test. B Not reviewed, Deleted

I-36 9 70 First-trimester NT should be interpreted for risk assessment only when performed by a trained 

sonographer who is accredited to provide this service [B] and when offered together with 

biochemical markers.

A Not reviewed, Deleted

I-36 10 70 For women who undertake first-trimester screening (FTS), second-trimester serum alpha 

fetoprotein (AFP) screening and/or ultrasound examination should be offered to screen for 

open neural tube defects (ONTD).

B Not reviewed, Deleted

I-36 11 70 Pregnant women with persistent unexplained elevations of maternal serum alphafetoprotein 

(MSAFP) are at increased risk for adverse perinatal outcome and should receive specialized 

prenatal care.

B Not reviewed, Amended Recommendation 14

I-36 12 70 The Quad Marker Screen should be used rather than the Triple Marker Screen when secondtrimester serum screening is undertaken.B Not reviewed, Deleted
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I-37 1 76 Recommend counseling and educating all pregnant women prior to scheduling sonographic 

studies about the potential benefits, limitations, and safety of prenatal ultrasound. 

Documentation of education and counseling is recommended; however, written informed 

consent is not deemed necessary.

C Not reviewed, Deleted

I-37 2 76 A complete obstetric sonographic examination should be recommended and available to 

women considering an invasive test on the basis of age, or other risk factors, when a more 

accurate gestational age is required for decision-making regarding medical or antenatal routine 

care interventions, or for predicting actual date of birth.

A Not reviewed, Deleted

I-37 3 76 A complete obstetric sonographic examination should be recommended and available to 

women or who are at increased risk for a songraphically detectable maternal or fetal 

abnormality where an intervention may improve the outcome (See table for list of indications).

A Not reviewed, Deleted

I-37 4 76 There is insufficient evidence to recommend for or against complete obstetric sonographic 

examination in the second trimester to all low-risk asymptomatic consenting pregnant women.

I Not reviewed, Deleted

I-37 5 76 All complete obstetric sonographic studies should be performed and interpreted by qualified 

healthcare providers.

A Not reviewed, Deleted

I-38 1 80 Pregnant women should be educated about the most common symptoms of preterm labor:

a. Low, dull backache

b. Four or more uterine contractions per hour. Uterine contractions may be perceived by the 

patient as:

‒ Menstrual-like cramps

‒ Sensation of the “baby rolling up in a ball”

‒ Increased uterine activity compared to previous patterns

‒ Abdominal cramping (may be associated with diarrhea)

c. Increased pelvic pressure (may be associated with thigh cramps)

d. Change in vaginal discharge such as change in color of mucus, leaking of clear fluid, spotting 

or bleeding or discharge associated with itching or fish-like odor immediately after 

intercourse.

e. Sensation that “something feels different” (e.g., agitation, flu-like syndrome, and sensation 

that baby has “dropped”).

None Not reviewed, Deleted

I-38 2 80 A pregnant woman who experiences any of the above symptoms or is unsure about the 

presence of any of the above, should lie down on her side with one of her hands on her lower 

abdomen to palpate for uterine contractions for an additional hour. If symptoms persist and/or 

she palpates four or more uterine contractions in the hour, she should seek immediate medical 

care. The exception to this is the pregnant woman who notes the presence of vaginal bleeding, 

leaking of clear fluid from the vagina, or a vaginal discharge with a fish-like odor immediately 

after intercourse, all of which should prompt immediate medical attention. 

I Not reviewed, Deleted
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I-38 3 80 Re-emphasize to the pregnant woman that she is the most important link in the early diagnosis 

of preterm labor, and that early diagnosis and treatment of preterm labor increases the 

chances for a healthy infant.

None Not reviewed, Deleted

I-38 4 80 Educate the pregnant woman that she can safely continue moderate exercise and activity 

during her pregnancy so long as she does not notice any of the symptoms of preterm labor. The 

exception to this is that she may notice some increase in uterine cramping with moderate 

exercise or activity. This is of no consequence so long as the cramping ceases when she stops 

her activity. She should limit her activity to no more than two hours per session.

B Reviewed, Amended Recommendation 13

I-38 5 80 Women with uncomplicated pregnancies may continue a standard work schedule throughout 

their pregnancy. If their work is strenuous or they spend long periods of time on their feet they 

should limit their work week to 40 hours and workday to eight hours during the last trimester 

(beginning at 28 weeks) or sooner if they frequently experience symptoms of preterm labor 

while at work. Pregnant women should attempt to limit periods of time on their feet to three 

hours.

B Not reviewed, Amended Recommendation 3 

I-38 6 80 There is no evidence that sexual intercourse increases the probability of preterm labor in 

women with uncomplicated pregnancy. They may experience some uterine contractions 

following orgasm; however, this is a normal response and she only needs to seek medical 

attention if they persist at four or more per hour for at least three hours, or if vaginal bleeding 

or spotting is noted. 

None Reviewed, Deleted

I-39 1 81 Appropriate candidates for a trial of labor include women with one prior low transverse 

cesarean and no other contraindications to labor or vaginal delivery. Women with two prior low 

transverse cesareans are candidates provided they have undergone a previous vaginal delivery.

B Not reviewed, Deleted

I-39 2 81 Women who meet the criteria for a possible trial of labor should be counseled regarding the 

risks and benefits of VBAC versus repeat low transverse cesarean delivery. Ideally, informed 

consent should be documented in the antepartum period after 24 weeks, and again at the time 

of admission for delivery.

None Not reviewed, Deleted

I-39 3 82 There is insufficient evidence to recommend for or against cesarean delivery on maternal 

request.

I Not reviewed, Deleted

I-40 1 83 Recommend screening all pregnant women for GDM at 24 to 28 weeks’ gestation. B Reviewed, NewreplacedRecommendation 10

I-40 2 83 Screening for GDM should be performed by randomly administering a 50 gram oral glucose 

tolerance test (GTT) followed by a blood draw one hour later. Generally accepted threshold 

values of the 1-hour screen are between 130 mg/dL and 140 mg/dL. Pregnant women who are 

positive require the diagnostic three-hour GTT.

B Reviewed, NewreplacedRecommendation 10 

I-40 3 83 In the three-hour GTT a 100-gram glucose load is administered to a woman who has fasted 

overnight (minimum eight hours). Blood draws are performed fasting and at one, two and three 

hours after the oral glucose load. No special diet is required before this test.

C Reviewed, NewreplacedRecommendation 10
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I-40 4 83 Two acceptable sets of threshold values for the three-hour 100-gram GTT can be used to 

diagnose gestational diabetes: the National Diabetes Data Group (NDDG) criteria and the 

Carpenter/Coustan conversion criteria. Institutions should adopt one of these two criteria sets 

based upon their population demographics. There should NOT be variance within the facility 

itself, though variance may occur between facilities.

B Reviewed, NewreplacedRecommendation 10 

I-40 5 83 For patients with only one abnormal value, consider one of the following: 

a. Undergo a repeat three-hour 100-gram glucose challenge test approximately one month 

following the initial test

b. Have dietary management and intermittent postprandial glucose testing performed in a 

manner similar to women with gestational diabetes.

C Reviewed, NewreplacedRecommendation 10 

I-40 6 83 Patients with a history of gastric bypass surgery may experience a “dumping” syndrome 

following ingestion of large quantities of simple sugar. An alternative to the 50-gram glucose 

tolerance test in these patients includes a fasting and two-hour postprandial finger sticks for 

one week. Target ranges are 90 mg/dL or lower fasting and 120 mg/dL or lower for 

postprandial.

C Reviewed, NewreplacedRecommendation 10 

I-41 1 85 There is insufficient evidence to recommend for or against routinely supplementing iron for all 

pregnant women.

I Not reviewed, Deleted

I-41 2 85 Women exhibiting signs or symptoms of anemia at any time during their pregnancy should be 

evaluated upon presentation.

I Not reviewed, Deleted

I-41 3 85 Obtain a serum ferritin if iron deficiency anemia is suspected. Recommend supplementing with 

at least 50 mg elemental iron (325 mg ferrous sulfate) twice a day (bid) in all pregnant women 

diagnosed with iron deficiency anemia (abnormal ferritin).

B Not reviewed, Deleted

I-42 1 86 Recommend determination of paternal erythrocyte antigen status for screen-positive women. I Not reviewed, Deleted

I-42 2 86 Recommend administering anti-D prophylaxis to all unsensitized D-negative pregnant women. B Not reviewed, Deleted

I-42 3 86 Recommend using either 300 mcg of anti-D immunoglobulin at 28 weeks or 100 mcg of antiDimmunoglobulin at 28 and 34 weeks’ gestation.

I Not reviewed, Deleted

I-42 4 86 Pregnant women who have had isoimmunization in a previous pregnancy or who are screened 

positive for antibody screen should be referred to a Maternal Fetal Medicine specialist for care.

A Not reviewed, Deleted
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Grade3

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I-43 1 88 Pregnant women should be educated about the most common symptoms of preterm labor:

a. Low, dull backache

b. Four or more uterine contractions per hour. Uterine contractions may be perceived by the 

patient as:

‒ Menstrual-like cramps

‒ Sensation of the “baby rolling up in a ball”

‒ Increased uterine activity compared to previous patterns

‒ Abdominal cramping (may be associated with diarrhea)

c. Increased pelvic pressure (may be associated with thigh cramps)

d. Change in vaginal discharge such as change in color of mucus, leaking of clear fluid, spotting 

or bleeding or discharge associated with itching or fish-like odor immediately after 

intercourse.

e. Sensation that “something feels different” (e.g., agitation, flu-like syndrome, and sensation 

that baby has “dropped”).

None Not reviewed, Deleted

I-43 2 88 A pregnant woman who experiences any of the above symptoms or is unsure about the 

presence of any of the above, should lie down on her side with one of her hands on her lower 

abdomen to palpate for uterine contractions for an additional hour. If symptoms persist or she 

palpates four or more uterine contractions in the hour, she should seek immediate medical 

care. The exception to this is the pregnant woman who notes the presence of vaginal bleeding, 

leaking of clear fluid from the vagina or a vaginal discharge with a fish-like odor immediately 

after intercourse, all of which should prompt immediate medical attention.

None Not reviewed, Deleted

I-43 3 88 If no diagnosis of preterm labor is established, continuation in the guideline is appropriate. None Not reviewed, Deleted

I-44 1 89 Recommend instructing all pregnant women about the importance of assessing fetal movement 

on a daily basis beginning in the third trimester.

B Not reviewed, Deleted

I-44 2 89 Recommend instructing all pregnant women as to the course of action they should take if they 

do not perceive the minimum fetal movement counts within the time frame specific to their 

healthcare facility.

B Not reviewed, Deleted

I-45 1 90 Recommend antepartum counseling and educating all pregnant women regarding family 

planning, to include various temporary contraceptive means and/or permanent sterilization.

C Not reviewed, Deleted

I-46 1 90 Recommend screening all pregnant women for Group B streptococcus (GBS) at 35 to 37 weeks’ 

gestation, using a rectovaginal culture and selective broth media to identify colonized women.

B Not reviewed, Deleted

I-46 2 90 Screening should be repeated every four weeks until delivery. C Not reviewed, Deleted
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I-46 3 90 Pregnant women with positive rectovaginal cultures should be treated with intrapartum IV 

chemoprophylaxis with either Penicillin or Ampicillin (if no contraindications) (a).

(a)Management of the GBS-colonized parturient with a history of an allergic reaction to 

penicillin agents: due to emerging resistance to previous second-line antimicrobial agents, 

clindamycin and erythromycin (10 to 15 percent resistant strains in most centers), alternative 

second-line agents for women with a history of allergic reactions to penicillin or ampicillin are 

listed below: 

a. Administer cefazolin 2gm IV load, followed by 1 gm IV every eight hours, for allergic reaction 

other than immediate hypersensitivity

b. Administer vancomycin 1 gm IV load, followed by 1 gm IV every 12 hours, for immediate 

hypersensitivity reaction (anaphylaxis, dyspnea, rapid onset of urticarial rash).

A Not reviewed, Deleted

I-46 4 90 Pregnant women who have had a previous child with early-onset GBS infection or have GBS 

bacteruria in the current pregnancy should receive intrapartum antibiotics, without screening 

cultures.

A Not reviewed, Deleted

I-47 1 93 Recommend screening for non-cephalic presentation for all patients at 36 weeks’ gestation. B Not reviewed, Deleted 

I-47 2 93 There is insufficient evidence to recommend for or against Leopolds versus cervical exam as the 

best screening method to determine fetal presentation.

I Not reviewed, Deleted

I-47 3 93 Recommend ultrasound for confirmation, if non-cephalic presentation is suspected. B Not reviewed, Deleted

I-47 4 93 If non-cephalic presentation is confirmed and there are no contraindications, recommend 

external cephalic version at 37 weeks or beyond and referral to an advanced prenatal care 

provider.

B Not reviewed, Deleted

I-48 1 94 Consider offering routine membrane sweeping to all pregnant women every visit beginning at 

38 weeks.

C Not reviewed, Deleted 

I-48 2 94 There is insufficient data to encourage or discourage this practice in women known to be GBScolonized.I Not reviewed, Deleted 

I-49 1 94 In the absence of contraindications, labor induction should be offered to women who reach 41 

and 0/7 weeks undelivered.

A Not reviewed, Amended Recommendation 12

I-49 2 95 In those patients with a favorable cervix (Bishop score > 6), induction after 39 weeks may be 

considered.

B Not reviewed, Deleted

I-49 3 95 When labor induction is offered or planned, women should be educated on the risks of 

induction, including length of induction, discomfort involved, and the process in determining 

appropriate timing of induction.

B Not reviewed, Deleted

I-49 4 95 Antepartum fetal testing should begin as soon as possible after 41 and 0/7 weeks if not 

scheduled for induction at this time.

C Not reviewed, Amended Recommendation 12

I-49 5 95 Testing should consist of weekly amniotic fluid assessment and twice weekly non-stress testing 

(NST).

C Not reviewed, Deleted
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I-49 6 95 Inadequate amniotic fluid index should prompt further evaluation to determine the need for 

delivery.

B Not reviewed, Deleted

I-50 1 96 Offer vaccination before postpartum discharge to all women < 26 years of age who have not 

previously completed HPV vaccination series.

B Not reviewed, Deleted

I-50 2 96 Women who begin their HPV vaccination series in the immediate postpartum period should 

complete the series with subsequent vaccinations at two months and six months following the 

first injection in the series. The eight-week postpartum visit provides an opportunity for the 

second injection.

C Not reviewed, Deleted

I-50 3 96 Vaccination to protect against HPV in individuals with a history of dysplasia is controversial and 

the decision to proceed in this situation should be made between a patient and her provider.

I Not reviewed, Deleted

I-50 4 96 Women who have initiated the HPV vaccine series before becoming pregnant should halt the 

series during pregnancy, and resume after delivery.

I Not reviewed, Deleted

I-50 5 96 HPV vaccination may be given to lactating women. I Not reviewed, Deleted

I-51 1 97 All pregnant women and fathers should receive education about Shaken Baby Syndrome prior 

to discharge from the hospital.

I Not reviewed, Deleted

I-52 1 99 Recommend against routine screening for preterm birth with fetal fibronectin (fFN) test. D Not reviewed, Amended Recommendation 15

I-52 2 99 Utilization of fFN testing in symptomatic women between 24 and 34 6/7 weeks’ gestation may 

be useful in guiding management of women with signs and symptoms of preterm labor.

B Not reviewed, Amended Recommendation 16

I-53 1 100 Recommend against performing cervical examination to screen for preterm birth prevention in 

low-risk asymptomatic pregnant women.

D Not reviewed, Deleted

I-54 1 100 Recommend against the use of antenatal pelvimetry (clinical or radiographic) in routine 

prenatal care.

D Not reviewed, Deleted

I-54 2 100 There is fair evidence that clinical pelvimetry is not effective in predicting the actual occurrence 

of cephalopelvic disproportion (CPD), and its performance is associated with significant increase 

in cesarean section rates.

D Not reviewed, Deleted

I-55 1 101 Recommend against the use of urine dipstick testing for protein and glucose during prenatal 

visits (the appropriate screening test for gestational diabetes is the one-hour glucola).

D Not reviewed, Deleted

I-55 2 101 Recommend the use of selective laboratory urinalysis for pregnant women with signs or 

symptoms of preeclampsia.

B Not reviewed, Deleted 

I-56 1 102 Recommend against routine evaluation for edema in pregnancy. D Not reviewed, Deleted

I-57 1 102 The evidence is insufficient to recommend for or against routine screening for cytomegalovirus 

(CMV).

I Not reviewed, Deleted

I-57 2 102 Recommend counseling pregnant women about methods to prevent acquisition of CMV during 

pregnancy.

C Not reviewed, Deleted
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I-58 1 103 Recommend against routine testing for parvovirus in pregnancy. D Not reviewed, Deleted

I-59 1 103 Recommend against routine testing for toxoplasmosis in pregnancy. D Not reviewed, Deleted

I-59 2 103 Recommend counseling pregnant women about methods to prevent acquisition of 

toxoplasmosis during pregnancy.

C Not reviewed, Deleted

I-60 1 104 Recommend against routine screening for bacterial vaginosis in asymptomatic pregnant 

women.

D Not reviewed, Deleted

I-61 1 105 Recommend against routine measles/mumps/rubella (MMR) immunization during pregnancy. D Not reviewed, Deleted 

I-62 1 106 Recommend against routine varicella vaccination in pregnancy. D Not reviewed, Deleted

I-62 2 106 Recommend serological testing early in pregnancy for all pregnant women with a negative or 

uncertain history.

B Not reviewed, Deleted

I-62 3 106 Recommend offering vaccination postpartum to pregnant women who are non-immune. B Not reviewed, Deleted

I-63 1 106 Recommend against routine cervical length screening at 24 weeks’ gestation. D Not reviewed, Deleted

I-64 1 107 Recommend against routine repeat screening for blood group antibodies. D Not reviewed, Deleted

I-64 2 107 Recommend against routine repeat screening for anemia and syphilis. D Not reviewed, Deleted 

I-64 3 107 Recommend providers consider repeat testing for anemia or syphilis at 24 to 28 weeks for 

women who are at higher risk for these conditions.

C Not reviewed, Deleted

I-65 1 108 Recommend against routine screening for thyroid hormone status of the mother. D Not reviewed, Deleted

I-65 2 108 Recommend ensuring adequate iodine intake during pregnancy for pregnant women in areas of 

the country with questionable levels of dietary iodine.

C Not reviewed, Deleted
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 107 of 147

Appendix E: Participant List

Heather Able, MSN, RNC (Champion)

Maternity Care Coordinator, VA Northern 

California Health Care System 

Senior Maternity Care Consultant, Women’s Health 

Services, Office of Patient Care Services, VA Central 

Office, Washington, DC

Alicia Christy, MD, MHSCR, FACOG (Champion)

Deputy Director, Reproductive Health

Women's Health Services (10P4W)

Office of Patient Care Services/Veteran Health 

Administration, Washington, DC

Professor, Uniformed Services University of Health 

Sciences, Department of Obstetrics and 

Gynecology, Bethesda, MD

COL Lisa Foglia, MD, FACOG (Champion)

Director, Maternal Fetal Medicine Fellowship, Joint 

Base Lewis-McChord, WA

Associate Professor, Uniformed Services University 

of Health Sciences, Bethesda, MD

Lt Col Barton Staat, MD, FACOG (Champion)

Air Force Surgeon General Consultant for 

Obstetrics/Maternal-Fetal Medicine

Vice-Chair of Patient Safety & Quality

Associate Professor, Uniformed Services University 

of Health Sciences, Bethesda, MD

Grace Chang, MD, MPH

Chief, Consultation Liaison Psychiatry

VA Boston Healthcare System

Boston, MA

CPT Allison M. DeLuca, CNM, RN

Certified Nurse Midwife, OB-GYN

Madigan Army Medical Center

Joint Base Lewis-McChord, WA

Megan Gerber, MD, MPH

Medical Director, Women’s Health VA Boston

Healthcare System

Director, VA Advanced Fellowship in Women 

Veterans Health/BU General Internal Medicine

Fellowship

Boston, MA

Barbara J. Hector, WHNP

Women Veterans Program Manager

South Texas Veterans Health Care System

San Antonio, TX

Maj Minette Herrick, MS, RDN, IBCLC

Chief of Health Promotion Air Force Medical 

Operations Agency

Joint Base San Antonio, TX

Carrie Kairys, DNP, FNP-BC

Deputy Field Director Area 2, Women's Health

Services (10P4W)

Office of Patient Care Services/Veteran Health

Administration

West Palm Beach, FL

LT Karla Krasnoselsky, MSC, DPT, CSCS

United States Navy

USS George Washington (CVN 73) Physical

Therapist Health Promotions and Wellness

Program Director

Jacqueline H. Langston, BSN, RN, Nurse Midwife

Maternity Care Coordinator

Charge Nurse, Fort McPherson Community Based 

Outpatient Clinic, Women’s Center of Excellence

Atlanta VA Medical Center 

Atlanta, GA
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 108 of 147

MAJ Sheila A. Medina, DNP, FNP-C

Army Nurse Corps

Director, Uniformed Services University of Health 

Sciences, Doctor of Nursing, Bethesda, MD

Practice Phase II Site, Carl R. Darnall Army Medical 

Center, Fort Hood, TX

Laura J. Miller, MD

Medical Director of Women's Mental Health

Edward Hines Jr. VA Hospital

Hines, IL

Ki Park, MD, MS, FSCAI

Malcolm Randall VA Medical Center

Gainesville, FL

Deanna Rolstead, MD, FACOG

Interim Chief of Gynecology, Phoenix VA 

Healthcare System, Phoenix, AZ

Senior Gynecology Consultant Women’s Health 

Services, Office of Patient Care Services, VA Central 

Office, Washington, DC

COL Cynthia Sanchez, MSN, RN

Chief, Women's Health Service Line

PCI, G-3/5/7, Office of the Surgeon General

Falls Church, VA

CDR Robert Selvester, MD

Director, Navy Medical Modeling and Simulation 

Program/Emerging Technologies Navy Medicine 

Education, Training, and Logistics Command JB 

San Antonio, TX

Kristi Shearer, PhD

Clinical Psychologist

Madigan Army Medical Center

Joint Base Lewis-McChord, WA

Elaine Stuffel, BSN, MHA, RN

Chronic Disease Nurse Consultant CPG Coordinator

US Army Medical Command

Clinical Performance Assurance Directorate (CPAD)

Office of Evidence Based Practice

Joint Base San Antonio-Fort Sam Houston, TX

CDR Christopher Tatro, MD, FACOG

Chief Medical Information Officer, Bureau of 

Medicine and Surgery, Pacific

Northwest Detachment

Bremerton, WA
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 109 of 147

Appendix F: Literature Review Search Terms and Strategy

A. Topic- Topic-specific Search Terms

The search strategies employed combinations of free-text keywords as well as controlled vocabulary terms 

including (but not limited to) the following concepts. Strategies for each bibliographic database follow the 

below tables (Table F-1, Table F-2, Table F-3, Table F-4). 

Table F-1. EMTREE, Medical Subject Headings (MeSH), PsycINFO, and Keywords 

Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

General 

Population 

Terms

Pregnant 

women/women 

undergoing 

prenatal care

'perinatal care'/de

'perinatal period'/de

pregnancy/exp

pregnancy/mj

‘pregnancy disorder’/exp

‘pregnancy outcome’/de

'pregnant woman'/de

'prenatal care'/de

'prenatal period'/de

PsycINFO

adolescent pregnancy/

antepartum period/

perinatal period/

pregnancy/

prenatal care/

postnatal period/

antenatal

antepartum

maternal

obstetric

perinatal

post-natal

post-partum

postpartum

postnatal

pre-natal

pregnancy

prenatal

trimester

Fetuses 'parameters concerning 

the fetus, newborn and 

pregnancy'/exp

‘prenatal disorder’/de

fetal

fetus*

foetal

foetus*

neonat*

Question 1 – 

Screening and 

Diagnosing 

Gestational 

Diabetes 

Mellitus in 

Pregnant 

Women

Pregnant women at 

risk of developing 

gestational 

diabetes)

'pregnancy diabetes 

mellitus'/exp/mj

'gestational diabetes'

Pre-existing 

diabetes (for 

exclusion)

N/A 'pre-existing'

preexisting

'pre-gestational'

pregestational

type
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Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 1 – 

Screening and 

Diagnosing 

Gestational 

Diabetes 

Mellitus in 

Pregnant 

Women (cont.)

Glucose tolerance, 

HbA1c, fasting 

blood sugar, other 

tests

diagnosis/exp/mj

'glycosylated 

hemoglobin'/exp/mj

'glucose tolerance 

test'/exp/mj

'2-step'

A1c

diagnos*

'glucose challenge'

'glucose tolerance'

identif*

measur*

'oral glucose'

'one-step'

screen*

'two-step'

fasting AND glucose

fasting AND ‘blood sugar’

HbA1c

test*

Question 2 – 

Patients Likely 

to Respond to 

Aspirin for 

Prevention of 

Preeclampsia

Aspirin 'acetylsalicylic acid'/mj 'acetylsalicylic acid'

aspirin

Prevention N/A manag*

prevent*

prophyla*

therap*

treat*

Preeclampsia, 

preeclampsia 

necessitating 

preterm birth, 

recurrence in 

women with history

'eclampsia and 

preeclampsia'/mj

preeclampsia/mj

eclampsia

HELLP

(hyperten* OR toxem*):ti AND 

(pregnancy/exp/mj OR (perinatal* OR 

pregnan*))

'pre-eclampsia'

‘pre-term’

preeclampsia

preterm
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Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 3 – 

Nutritional 

Interventions for 

Pregnant 

Women Who 

Have Had 

Bariatric Surgery

Women with a 

history of bariatric 

surgery

'bariatric surgery'/exp

'gastric bypass 

surgery'/de

gastrojejunostomy/de

gastroplasty/de 

bariatric

'metabolic surgery'

biliopancreatic

'bilio-pancreatic'

'duodenal switch'

'gastric balloon'

gastric NEXT/1 band*

'gastric bypass'

gastric NEXT/1 sleeve*

gastroplast*

'jejunoileal bypass'

lapband

'lap-band'

'obesity surgery'

'roux-en-Y'

'sleeve gastrectomy'

'stomach stapling'

'weight loss surgery'

Nutritional 

screening, 

nutritional 

management, 

dietary 

supplements

nutrition/exp

'nutritional disorder'/exp

anem*

B 

B12

calcium

deficien*

folate

‘folic acid’

iron

macronutrient*

malnutrition

micronutrient*

nutrient*

nutrition*

supplement*

vitamin*

Dumping syndrome 'dumping syndrome'/de dumping NEXT/1 syndrome*

'gastric emptying'

Gestational 

diabetes

pregnancy diabetes 

mellitus'/exp/mj

'gestational diabetes'

(pregnancy/mj OR maternal:ti OR 

pregnan*) AND diabetes

Glucose tolerance 

testing

'glucose tolerance 

test'/exp/mj

'glucose challenge' OR 'glucose tolerance' 

OR 'oral glucose' OR fasting
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Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 4 – 

Comparative 

Accuracy, 

Clinical Utility, 

and Cost of 

Methods of 

Aneuploidy 

Screening

Aneuploidy aneuploidy/exp

'down syndrome'/de

'klinefelter syndrome'/de

trisomy/exp

'turner syndrome'/de

aneuploid*

‘down syndrome’

‘downs syndrome’

klinefelter*

trisom*

turner*

Cell-free fetal DNA 

testing

'non invasive 

measurement'/de 

cffDNA

cellfree

'cell-free'

'fetal DNA'

'fetal nucleic acid'

'fetal nucleic acids'

'foetal DNA'

'foetal nucleic acid'

'foetal nucleic acids'

'noninvasive prenatal'

'non-invasive prenatal'

'prenatal diagnosis'

Maternal serum, 

nuchal

translucency, 

amniocentesis, and 

other tests

amniocentesis/exp

'chorion villus 

sampling'/de

'diagnostic test accuracy 

study'/de

'maternal serum 

screening'/de

'nuchal translucency 

measurement'/de

'prenatal diagnosis'/de

'prenatal screening'/de 

AFP

amniocentesis

biochemical

biomarker*

'chorionic villus'

‘combined test’

‘double test’

e3

hCG

‘inhibin A’

marker*

'nuchal fold'

'nuchal thickness'

'nuchal translucency'

PAPP-A 

'quadruple test'

screen*

test*

‘triple test’

ultrasonography*

ultrasound

Topic of special 

interest

N/A (advanced OR anatomy OR anomaly OR 

detailed OR ‘level II’ OR ‘level 2’ OR ‘second 

trimester’ OR targeted) NEXT/3 (scan OR 

scans OR sonogram OR sonograms OR 

ultrasonography OR ultrasound*)
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Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 5 – 

Perinatal 

Screens for 

Psychiatric and 

Substance Use 

Disorders 

Compared with 

Routine 

Screening 

Methods

Perinatal surveys 

and other routine 

surveys

N/A '4-Ps plus'

'4-P plus' OR '4P plus' 

'4Ps plus' 

'alcohol use disorders identification test'

AUDIT AND alcohol

C-BIAP

EPDS*

'edinburg postnatal depression scale'

GAD-7 

GAD7

NET AND (alcohol OR drinker OR drinking)

'patient health questionnaire'

PDSS

PHQ

PHQ9

'postpartum depression screening scale'

T-ACE

T-ACER-3 

TACER3

TWEAK

Drug testing 'drug analysis'/exp/mj

'drug urine level'/mj 

'laboratory diagnosis'/mj 

urinalysis/mj 

'diagnostic accuracy'/mj 

'diagnostic error'/mj 

'diagnostic test'/mj 

'mental disease 

assessment'/exp/mj 

'psychiatric diagnosis'/mj 

'self report'/mj 

PsycINFO

"drug usage screening"/

urinalysis/

psychological 

assessment/

"self-report"/

assess*

bioanalysis

checklist*

detect*

diagnos*

index*

indices

instrument*

inventories

inventory

measure*

profile*

questionnaire*

scale

screen*

self NEXT/1 report*

survey* 

test*

tool*

Psychiatric 

disorders

'mental disease'/de

PsycINFO

exp affective disorders/

behavior disorders/

mental disorders/

(anxiety OR behavior* OR behavior* OR 

mood) NEXT/1 disorder*

bipolar

depress*

(mental* OR psychiatric) NEXT/1 

(condition* OR disease* OR disorder* OR 

health OR ill OR illness*)
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Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 5 – 

Perinatal 

Screens for 

Psychiatric and 

Substance Use 

Disorders 

Compared with 

Routine 

Screening 

Methods (cont.)

Substance use 

disorders

addiction/de

'drug abuse'/de

'drug dependence'/exp

'substance abuse'/de

PsycINFO

addiction/de

'drug abuse'/de

'drug dependence'/exp

'substance abuse'/de

addict*

dependen*

'drug abuse'

'drug exposure'

'drug use'

Illicit

'substance abuse'

'substance use'

alcohol

amphetamine*

cocaine

heroin

marijuana

methadone

morphine

opiate*

opioid*

Question 6 – 

First Trimester 

Ultrasound to 

Establish or 

Confirm 

Gestational Age

Measurement N/A accura*

adjust*

agree*

assess*

calculat*

confirm*

determin*

discrepan*

establish*

estimate*

measur*

predict*

Pregnancy 

dating/Gestational 

age

'gestational age'/mj (delivery OR due OR pregnancy) NEAR/2 

date

(fetal OR foetal OR fetus OR foetus OR 

gestational) NEAR/2 age

‘gestational age dating'

'pregnancy dating'

'trimester dating'

Ultrasound ultrasound/de

'fetus echography'/exp

echograph*

sonogra*

ultrasonograph*

ultrasound*

US

Ultrasound dating N/A 'ultrasound dating'
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

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Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 7 – 

Factors or 

Interventions 

That Improve 

Outcomes 

Related to 

Breastfeeding

Breastfeeding 'breast feeding'/exp/mj 'breast feeding'

breastfeeding

Breast examination 'breast examination'/de breast NEXT/1 exam*

Formal education 

programs

'breast feeding 

education'/exp

education/de

'health education'/de

'childbirth education'/de

'health promotion'/de

'lactation consultant'/de

'nutrition education'/de

'parenting education'/de

'patient education'/de

'program evaluation'/exp

class*

course*

educat*

program*

Experience, 

preparation, 

promotion

N/A attitud*

consult*

determinant*

duration*

encourag*

experienc*

guidance

improv*

initiat*

knowledg*

likel*

prepar*

promot*

provider*

success*

support*

train*

Reoccurring 

concept

N/A (breastfeeding OR 'breast feeding') AND 

initiat*
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 116 of 147

Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 8 – 

Impact of 

Exercise 

Frequency, 

Type, and 

Intensity on 

Maternal and 

Fetal Outcomes

Formal exercise exercise/exp/mj

'physical activity'/exp/mj

sport/exp/mj

aerobic*

athletic*

aquatic*

bicycling

cycling

dancing

exercis*

fitness

hiking

jogging

physical NEXT/1 activit*

running

sports

swimming

walking

yoga

Question 9 – 

Pregnancyrelated 

Complications 

and Risk of 

Adverse LifeTime Health 

Outcomes

Specific pregnancy 

complications

'eclampsia and 

preeclampsia'/mj

'maternal 

hypertension'/de

preeclampsia/mj

'pregnancy diabetes 

mellitus'/exp/mj

eclampsia

'gestational diabetes'

(gestational OR maternal OR pregnancy) 

AND hypertensi*

'pre-eclampsia'

preeclampsia

Adverse life-time 

health outcomes

'cardiovascular 

risk'/exp/mj

'chronic disease'/de

'life expectancy'/de OR 

lifespan/de

chronic

course

decade*

future

later

later NEXT/2 life

'life expectancy'

'life-long'

lifelong

'life-span'

lifespan

'life-time'

lifetime

'long term' 

longterm

subsequent

years AND (after OR 'follow-up' OR 

followup OR later OR 'post-partum' OR 

postpartum)
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 117 of 147

Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 10 – 

Maternal Age 

and Gestational 

Age and 

Consideration 

for Antepartum 

Surveillance and 

Planned 

Delivery

Women of 

advanced maternal 

age

'maternal age'/mj (35 OR 40 OR 50) NEAR/3 (age* OR old OR 

year*)

40s

advance* NEXT/1 age*

forties

middle NEXT/1 age*

older 

Antepartum 

surveillance and 

planned delivery

amniocentesis/exp

'chorion villus 

sampling'/de

'blood pressure 

monitoring'/de

'diagnostic 

procedure'/exp

echography/exp

monitoring/de

'obstetric operation'/exp

'obstetric procedure'/de

'patient monitoring'/exp

'physiologic 

monitoring'/exp

'perinatal care'/exp

'prenatal care'/exp

'prenatal diagnosis'/de

'risk management'/de

'risk reduction'/de

ultrasound/de

'uterine activity 

monitoring'/de 

care

‘expectant management’

induc*

manag*

monitor*

plan*

observ*

schedul*

sonogra*

surveillance

test*

ultrasound*

ultrasonogra*
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 118 of 147

Concept 

Controlled Vocabulary

(EMTREE unless 

otherwise noted) Keywords

Question 10 – 

Maternal Age 

and Gestational 

Age and 

Consideration 

for Antepartum 

Surveillance and 

Planned 

Delivery (cont.)

Identification of risk 'fetus control'/exp

'fetus disease'/exp

'fetus mortality'/de

'fetus outcome'/de

'fetus risk'/de

hypertension/de

'high risk infant'/de

'high risk patient'/de

'high risk population'/de

'high risk pregnancy'/de

'labor complication'/de

'intermediate risk 

patient'/de

'intermediate risk 

population'/de

'maternal 

hypertension'/de

'maternal morbidity'/de

'maternal mortality'/de

miscarriage/de

'perinatal morbidity'

'perinatal mortality'/exp

'placenta disorder'/exp

'pregnancy 

complication'/exp

'pregnancy disorder'/de

'pregnancy loss'/de

'pregnancy outcome'/de

'pregnancy toxemia'/exp

'premature labor'/de

risk/de OR

'risk assessment'/de

'risk factor'/de

stillbirth/de

aneuploid*

'c-section'

caesarean

cesarean

down*

chromosom*

'gestational diabetes'

'high blood pressure'

hypertensi*

'low birth weight'

miscarriage*

placenta*

multiple*

'pregnancy loss'

prematur*

preterm OR risk*

trisom*

twin

twins
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 119 of 147

B. Search Strategies

Table F-2. PubMed

Question/Hedge Set # Concept Strategy

Question 1 – 

Screening and 

Diagnosing 

Gestational 

Diabetes 

Mellitus in 

Pregnant 

Women

#1 Population (pregnant 

women, women at risk of 

developing gestational 

diabetes)

"gestational diabetes"[tiab] OR (gestational[ti] AND 

diabetes[ti])

#2 ((maternal[ti] OR pregnan*[ti]) AND diabetes[ti]) NOT 

("pre-existing"[ti] OR preexisting[ti] OR "pregestational"[ti] OR pregestational[ti] OR type[ti])

#3 Combine #1 OR #2

#4 Intervention (glucose 

tolerance, HbA1c, fasting 

blood sugar, others)

"glucose challenge"[ti] OR "glucose tolerance"[ti] OR 

"oral glucose"[ti] OR "one-step"[ti] OR "two-step"[ti] OR 

"2-step"[ti] OR (fasting[ti] AND (glucose[ti] OR "blood 

sugar"[ti])) OR HbA1c[ti] OR A1c[ti] OR ((glycated[ti] OR 

glycosylated[ti]) AND (haemoglobin[ti] OR 

hemoglobin[ti])) OR diagnos*[ti] OR identif*[ti] OR 

measur[ti] OR screen*[ti] OR test[ti] OR tested[ti] OR 

testing[ti] OR tests[ti]

#5 Combine #3 AND #4

Question 2 – 

Patients Likely to 

Respond to 

Aspirin for 

Prevention of 

Preeclampsia

#1 Intervention (aspirin) "acetylsalicylic acid"[ti] OR aspirin[ti]

#2 Outcome (preeclampsia, 

preeclampsia necessitating 

preterm birth, recurrence 

in women with history)

"pre-eclampsia"[ti] OR preeclampsia[ti] OR eclampsia[ti] 

OR HELLP[ti] OR pre-term[ti] OR preterm[ti] OR 

((hyperten*[ti] OR toxem*[ti]) AND (perinatal*[tiab] OR 

pregnan*[ti]))

#3 Combine #1 AND #2

#4 Broad intervention 

(aspirin)

"acetylsalicylic acid"[tiab] OR aspirin[tiab]

#5 Broad intervention 

(prevention)

prevent*[tiab] OR prophyla*[tiab] OR manag*[tiab] OR 

therap*[tiab] OR treat*[tiab]

#6 Broad outcome 

(preeclampsia and related 

indications)

"pre-eclampsia"[tiab] OR preeclampsia[tiab] OR 

eclampsia[tiab]

#7 Combine (#4 OR #5) AND #6

Question 3 – 

Nutritional 

Interventions for 

Pregnant 

Women Who 

Have Had 

Bariatric Surgery

#1 Population (pregnant 

women)

antenatal[ti] OR fetal[ti] OR fetus*[ti] OR foetal[ti] OR 

foetus*[ti] OR maternal*[ti] OR neonat*[ti] OR 

perinatal*[ti] OR pregnan*[ti] OR prenatal*[ti]

#2 Subpopulation (women 

with a history of bariatric 

surgery) text words

bariatric[ti] OR "metabolic surgery"[ti] OR 

biliopancreatic[ti] OR "bilio-pancreatic"[ti] OR "duodenal 

switch"[ti] OR "gastric balloon"[ti] OR "gastric band"[ti] 

OR "gastric banding"[ti] OR "gastric bypass"[ti] OR 

"gastric sleeve"[ti] OR gastroplast*[ti] OR "jejunoileal 

bypass"[ti] OR lapband[ti] OR "lap-band"[ti] OR "obesity 

surgery"[ti] OR "Roux-en-Y"[ti] OR "sleeve 

gastrectomy"[ti] OR "stomach stapling"[ti] OR "weight 

loss surgery"[ti]

#3 Combine population sets #1 AND #2

#4 Limit broad set to metaanalyses and systematic 

reviews

#3 AND See hedge at end of table
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 120 of 147

Question/Hedge Set # Concept Strategy

Question 3 – 

Nutritional 

Interventions for 

Pregnant 

Women Who 

Have Had 

Bariatric Surgery

(cont.) 

#5 Intervention (nutritional 

screening, nutritional 

management, dietary 

supplements) text words

anem*[tiab] OR deficien*[tiab] OR macronutrient*[tiab] 

OR malnutrition[tiab] OR micronutrient*[tiab] OR 

nutrient*[tiab] OR nutrition*[tiab] OR 

supplement*[tiab] OR vitamin*[tiab] OR B[tiab] OR 

B12[tiab] OR calcium[tiab] OR folate[tiab] OR "folic 

acid"[tiab] OR iron[tiab] OR "dumping syndrome"[tiab] 

OR "gastric emptying"[tiab] OR diabetes[tiab] OR 

"glucose challenge"[tiab] OR "glucose tolerance"[tiab] 

OR "oral glucose"[tiab] OR fasting[tiab]

#6 Combine population and 

intervention set

#3 AND #5

#7 Combine sets #4 OR #6

Question 4 – 

Comparative 

Accuracy, 

Clinical Utility, 

and Cost of 

Methods of 

Aneuploidy 

Screening

#1 Population (pregnant 

women)

antenatal[tiab] OR maternal[tiab] OR obstet*[tiab] OR 

perinatal[tiab] OR prenatal[tiab] OR pregnan*[tiab] OR 

trimester[tiab]

#2 Population (fetus) fetal[tiab] OR fetus*[tiab] OR foetal[tiab] OR 

foetus*[tiab]

#3 Condition (aneuploidy) aneuploid*[tiab] OR "down syndrome"[tiab] OR "downs 

syndrome"[tiab] OR klinefelter*[tiab] OR trisom* OR 

turner*[tiab]

#4 Combine sets (#1 OR #2) AND #3

#5 Intervention (cell-free fetal 

DNA testing)

cffDNA[tiab] OR cellfree[tiab] OR "cell-free"[tiab] OR 

"fetal DNA"[tiab] OR "fetal nucleic acid"[tiab] OR "fetal 

nucleic acids"[tiab] OR "foetal DNA"[tiab] OR 

(foetal[tiab] AND nucleic[tiab] AND acid[tiab]) OR 

(foetal[tiab] AND nucleic[tiab] AND acids[tiab]) OR 

(noninvasive[tiab] AND prenatal[tiab]) OR "non-invasive 

prenatal"[tiab] OR "prenatal diagnosis"[tiab]

#6 Intervention (maternal 

serum, nuchal 

translucency, 

amniocentesis, and other 

tests)

"nuchal fold"[tiab] OR "nuchal thickness"[tiab] OR 

"nuchal translucency"[tiab] OR ultrasonography*[tiab] 

OR ultrasound[tiab] OR biochemical[tiab] OR 

biomarker*[tiab] OR marker*[tiab] OR PAPP-A[tiab] OR 

hCG[tiab] OR AFP[tiab] OR e3[tiab] OR "inhibin A"[tiab] 

OR "double test"[tiab] OR "triple test"[tiab] OR 

"quadruple test"[tiab] OR "combined test"[tiab] OR 

amniocentesis[tiab] OR "chorionic villus"[tiab] OR 

screen*[ti] OR test*[ti]

#7 Combine sets #4 AND (#5 OR #6)

#8 Intervention (special topic 

of interest)

scan[tiab] OR scans[tiab] OR sonogram[tiab] OR 

sonograms[tiab] OR ultrasonography[tiab] OR 

ultrasound*[tiab]

#9 anomaly[tiab] OR detailed[tiab] OR “level II”[tiab] OR 

“level 2”[tiab] OR targeted[tiab]

#10 “advanced ultrasound” OR “second trimester 

ultrasound” OR anomaly[tiab]

#11 “early anomaly”[tiab] OR “fetal anomaly scan”[tiab]

#12 Combine intervention sets #8 AND (#9 OR #10 OR #11)

#13 Combine sets #4 AND #12

#14 Combine two separate 

intervention sets

#7 OR #13
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 121 of 147

Question/Hedge Set # Concept Strategy

Question 5 – 

Perinatal 

Screens for 

Psychiatric and 

Substance Use 

Disorders 

Compared with 

Routine 

Screening 

Methods

#1 Population (pregnant 

women)

antenatal[ti] OR antepartum[ti] OR maternal[ti] OR 

obstet*[ti] OR perinatal[ti] OR post-natal[ti] OR 

postnatal[ti] OR post-partum[ti] OR postpartum[ti] OR 

pre-natal[ti] OR prenatal[ti] OR pregnan*[ti]

#2 Intervention (specific 

perinatal surveys and 

other routine surveys)

T-ACE[ti] OR TWEAK[ti] OR "4-Ps plus"[ti] OR "4-P 

plus"[ti] OR "4P plus"[ti] OR "4Ps plus"[ti] OR (NET[ti] 

AND (alcohol[ti] OR drinker[ti] OR drinking[ti])) OR 

EPDS*[ti] OR "edinburg postnatal depression scale"[ti] 

OR PDSS[ti] OR "postpartum depression screening 

scale"[ti] OR (AUDIT[ti] AND alcohol*[ti]) OR "alcohol 

use disorders identification test"[ti] OR PHQ9[ti] OR 

PHQ[ti] OR "patient health questionnaire"[ti] OR CBIAP[ti] OR GAD7[ti] OR GAD-7[ti] OR TACER3[ti] OR 

TACER-3[ti]

#3 Intervention (any survey or 

laboratory screening test 

for psychiatric or 

substance use disorders)

assess*[ti] OR bioanalysis[ti] OR checklist*[ti] OR 

detect*[ti] OR diagnos*[ti] OR index*[ti] OR indices[ti] 

OR instrument*[ti] OR inventories[ti] OR inventory[ti] 

OR measure*[ti] OR profile*[ti] OR questionnaire*[ti] OR 

scale[ti] OR screen*[ti] OR "self report"[ti] OR "self 

reports"[ti] OR survey*[ti] OR test[ti] OR tests[ti] OR 

tested[ti] OR testing[ti] OR tool*[ti]

#4 Condition (psychiatric 

disorder)

((mental*[ti] OR psychiatric[ti]) AND (condition*[ti] OR 

disease*[ti] OR disorder*[ti] OR health[ti] OR ill[ti] OR 

illness*[ti])) OR ((anxiety[ti] OR behavior*[ti] OR 

behavior*[ti] OR mood[ti]) AND disorder*[ti]) OR 

bipolar[ti] OR depress*[ti]

#5 Condition (substance use 

disorder)

addict*[ti] OR dependen*[ti] OR "drug abuse"[ti] OR 

"drug exposure"[ti] OR "drug use"[ti] OR illicit[ti] OR 

"substance abuse"[ti] OR "substance use"[ti] OR 

alcohol[ti] OR amphetamine*[ti] OR cocaine[ti] OR 

heroin[ti] OR marijuana[ti] OR methadone[ti] OR 

morphine[ti] OR opiate*[ti] OR opioid*[ti]

#6 Combine sets #3 AND (#4 OR #5)

#7 Combine sets #1 AND (#2 OR #6)

Question 6 – 

First Trimester 

Ultrasound to 

Establish or 

Confirm 

Gestational Age

#1 Pregnancy 

dating/establishing 

gestational age

"pregnancy dating"[tiab]

#2 (delivery[ti] OR due[ti] OR pregnancy[ti]) AND date[ti]

#3 (fetal[ti] OR foetal[ti] OR fetus[ti] OR foetus[ti] OR 

gestational[ti]) AND age[ti]

#4 "gestational age"[tiab] AND (agree*[ti] OR calculat*[ti] 

OR confirm*[ti] OR determin*[ti] OR establish*[ti] OR 

measur*[ti] OR predict*[ti])

#5 Combine sets #1 OR #2 OR #3 OR #4

#6 Intervention (ultrasound) echograph*[tiab] OR sonogra*[tiab] OR 

ultrasonograph*[tiab] OR ultrasound*[tiab] OR US[ti]

#7 Combine sets #5 AND #6
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 122 of 147

Question/Hedge Set # Concept Strategy

Question 7 – 

Factors or 

Interventions 

That Improve 

Outcomes 

Related to 

Breastfeeding

#1 Population (pregnant 

women/women receiving 

prenatal care)

antenatal[ti] OR obstet*[ti] OR perinatal[ti] OR 

prenatal[ti] OR pregnan*[tiab]

#2 Issue (breastfeeding) "breast feeding"[ti] OR breastfeeding[ti]

#3 Combine sets #1 AND #2

#4 Intervention (breast 

examination)

breast[ti] AND (exam[ti] OR exams[ti] OR 

examination*[ti])

#5 Intervention (formal 

education programs)

class*[ti] OR course*[ti] OR educat*[ti] OR program*[ti]

#6 Intervention (experience, 

preparation, promotion)

attitud*[ti] OR consult*[ti] OR determinant*[ti] OR 

duration*[ti] OR encourag*[ti] OR experienc*[ti] OR 

guidance[ti] OR improve*[ti] OR initiat*[ti] OR 

knowledg*[ti] OR likel*[ti] OR prepar*[ti] OR promot*[ti] 

OR provider*[ti] OR success*[ti] OR support*[ti] OR 

train*[ti]

#7 Combine intervention sets #4 OR #5 OR #6

#8 Combine all sets #3 AND #7

Question 8 – 

Impact of 

Exercise 

Frequency, Type, 

and Intensity on 

Maternal and 

Fetal Outcomes

#1 Population (pregnant 

women)

'perinatal care'/de OR 'perinatal period'/de OR 

pregnancy/exp OR 'pregnant women'/de OR 'prenatal 

care'/de OR 'prenatal period'/de OR (antenatal OR 

maternal OR obstet* OR perinatal OR prenatal OR 

pregnan*):ti

#2 Population (fetal) 'parameters concerning the fetus, newborn and 

pregnancy'/exp OR (fetal OR fetus* OR foetal OR 

foetus*):ti

#3 Issue (formal exercise) exercise/exp/mj OR 'physical activity'/exp/mj OR 

sport/exp/mj OR (aerobic* OR athletic* OR aquatic* OR 

bicycling OR cycling OR dancing OR exercis* OR fitness OR 

hiking OR jogging OR running OR sports OR swimming OR 

walking OR yoga OR (physical NEXT/1 activit*)):ti

#4 Combine sets (#1 OR #2) AND #3

Question 9 – 

Pregnancyrelated 

Complications 

and Risk of 

Adverse LifeTime Health 

Outcomes

#1 Population (pregnant 

women)

antenatal[ti] OR maternal[ti] OR obstet*[ti] OR 

perinatal[ti] OR prenatal[ti] OR pregnan*[ti]

#2 Issue (specific pregnancy 

complications)

"gestational diabetes"[ti] OR "pre-eclampsia"[ti] OR 

preeclampsia[ti] OR eclampsia[ti] OR ((gestational[ti] OR 

maternal[ti] OR pregnancy[ti]) AND hypertensi*[ti])

#3 Combine sets #1 AND #2

#4 Issue (adverse life-time 

health outcomes) EMTREE 

controlled vocabulary

later[tiab] AND life[tiab]

#5 Issue (adverse life-time 

health outcomes) text 

words

(years[ti] AND (after[ti] OR "follow-up"[ti] OR 

followup[ti] OR later[ti] OR "post-partum"[ti] OR 

postpartum[ti])) OR chronic[ti] OR course[ti] OR 

decade*[ti] OR future[ti] OR later[ti] OR "life 

expectancy"[ti] OR "life-long"[ti] OR lifelong[ti] OR "lifespan"[ti] OR lifespan[ti] OR "life-time"[ti] OR lifetime[ti] 

OR "long term"[ti] OR longterm[ti] OR subsequent[ti]

#6 Combine sets #4 OR #5

#7 Combine sets #3 AND #6
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 123 of 147

Question/Hedge Set # Concept Strategy

Question 10 – 

Maternal Age & 

Gestational Age 

and 

Consideration 

for Antepartum 

Surveillance and 

Planned Delivery

#1 Population (pregnant 

women)

antenatal[tiab] OR antepartum[tiab] OR maternal[tiab] 

OR obstet*[tiab] OR perinatal[tiab] OR prenatal[tiab] OR 

pregnan*[tiab] OR trimester*[tiab]

#2 Population (women of 

advanced maternal age)

40s[ti] OR forties[ti] OR older[ti] OR (middle[ti] AND 

age*[ti]) OR (advanc*[ti] AND age*[ti]) OR ((35[ti] OR 

40[ti] OR 50[ti]) AND (age*[ti] OR old*[ti] OR year*[ti]))

#3 Combine sets #1 AND #2

#4 Intervention (antepartum 

surveillance)

amniocentesis[ti] OR care[ti] OR chorion*[ti] OR

‘expectant management’ OR induc*[ti] OR manag*[ti] 

OR monitor*[ti] OR plan[ti] OR planned[ti] OR 

planning[ti] OR plans[ti] OR observ*[ti] OR sonogra*[ti] 

OR surveillance[ti] OR test[ti] OR tests[ti] OR tested[ti] 

OR testing[ti] OR ultrasound*[ti] OR ultrasonogra*[ti]

#5 Intervention (identification 

of risk)

aneuploid*[ti] OR "c-section"[ti] OR caesarean[ti] OR 

cesarean[ti] OR down*[ti] OR chromosom*[ti] OR 

"gestational diabetes"[ti] OR "high blood pressure"[ti] 

OR hypertensi*[ti] OR "low birth weight"[ti] OR 

miscarriage*[ti] OR placenta*[ti] OR multiple*[ti] OR 

"pregnancy loss"[ti] OR prematur*[ti] OR preterm[ti] OR 

risk*[ti] OR trisom*[ti] OR twin[ti] OR twins[ti]

#6 Combine sets #3 AND (#4 OR #5)

General Hedges 

Applied to Each 

Search

Limit to newly added 

results (inprocess, 

publisher)

AND (inprocess[sb] OR publisher[sb] OR 

pubmednotmedline[sb])

Exclude animal studies NOT (mouse[ti] OR mice[ti] OR rat[ti] OR rats[ti] OR 

rabbit*[ti] OR sheep[ti])

Limit to English language 

publications and results 

with abstracts

AND eng[la] AND hasabstract

Remove undesired 

publication types (e.g., 

case reports, comments)

NOT (year-old[tiab] OR "case report"[ti] OR 

comment[ti])

Limit by publication year AND 2007:2017[edat]

Study Type 

Hedges Applied

as Needed (per 

Key Question 

Specific Criteria 

provided earlier 

in this report)

Limit to studies that make 

comparisons

"case control"[tiab] OR compar*[tiab] OR "control 

group"[tiab] OR "controlled study"[tiab] OR "controlled 

trial"[tiab] OR "cross over"[tiab] OR crossover[tiab] OR 

"double blind"[tiab] OR "double blinded"[tiab] OR 

"matched controls"[tiab] OR placebo*[tiab] OR 

random*[tiab] OR sham[tiab] OR versus[ti] OR vs[ti]

Limit to meta-analyses and 

systematic reviews

"meta-analysis"[tiab] OR "meta-analytic"[tiab] OR 

metaanaly*[tiab] OR "research synthesis"[tiab] OR 

"systematic review"[tiab] OR pooled[tiab] OR 

pooling[tiab] OR search*[tiab] OR "critical review"[ti] OR 

"evidence-based"[ti] OR cochrane database syst rev[ta]
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 124 of 147

Table F-3. Embase/MEDLINE (presented in Embase syntax)

Question/Hedge Set # Concept Strategy

Question 1 – 

Screening and 

Diagnosing 

Gestational 

Diabetes 

Mellitus in 

Pregnant 

Women

#1 Condition (gestational 

diabetes)

'pregnancy diabetes mellitus'/exp/mj OR 'gestational 

diabetes':ti

#2 ((pregnancy/mj OR maternal:ti OR pregnan*:ti) AND 

diabetes:ti) NOT ('pre-existing' OR preexisting OR 'pregestational' OR pregestational OR type):ti

#3 Combine sets #1 AND #2

#4 Intervention (glucose 

tolerance, HbA1c, fasting 

blood sugar, others)

'glycosylated hemoglobin'/exp/mj OR 'glucose tolerance 

test'/exp/mj OR diagnosis/exp/mj OR ('glucose challenge' 

OR 'glucose tolerance' OR 'oral glucose' OR 'one-step' OR 

'two-step' OR '2-step' OR (fasting AND (glucose OR 'blood

sugar')) OR HbA1c OR A1c OR ((glycated OR glycosylated) 

AND (haemoglobin OR hemoglobin))):ti OR (diagnos* OR 

identif* OR measur* OR screen* OR test OR tested OR 

testing OR tests):ti

#5 Combine sets #3 AND #4

Question 2 – 

Patients Likely 

to Respond to 

Aspirin for 

Prevention of 

Preeclampsia

#1 Focused intervention 

(aspirin)

'acetylsalicylic acid'/mj OR ('acetylsalicylic acid' OR 

aspirin):ti

#2 Focused outcome 

(preeclampsia, 

preeclampsia 

necessitating preterm 

birth, recurrence in 

women with history)

'eclampsia and preeclampsia'/mj OR preeclampsia/mj OR 

('pre-eclampsia' OR preeclampsia OR eclampsia OR HELLP 

OR 'pre-term' OR preterm):ti OR ((hyperten* OR 

toxem*):ti AND (pregnancy/exp/mj OR (perinatal* OR 

pregnan*):ti))

#3 Combine sets #1 AND #2

#4 Broad intervention 

(aspirin)

'acetylsalicylic acid'/de OR ('acetylsalicylic acid' OR 

aspirin):ti,ab

#5 Broad intervention 

(prevention)

(prevent* OR prophyla* OR manag* OR therap* OR 

treat*):ti

#6 Broad outcome 

(preeclampsia and related 

indications)

'eclampsia and preeclampsia'/de OR preeclampsia/de OR 

('pre-eclampsia' OR preeclampsia OR eclampsia):ti,ab

#7 Combine sets (#4 OR #5) AND #6

#8 Combine focused and 

broad sets

#3 OR #7

Question 3 – 

Nutritional 

Interventions 

for Pregnant 

Women Who 

Have Had 

Bariatric Surgery

#1 Population (pregnant 

women)

'parameters concerning the fetus, newborn and 

pregnancy'/exp OR 'perinatal care'/exp OR 

pregnancy/exp OR 'pregnancy disorder'/exp OR 

'pregnancy women'/de OR 'pregnancy outcome'/de OR 

'prenatal care'/exp OR 'prenatal disorder'/exp

#2 (antenatal OR fetal OR fetus* OR foetal OR foetus* OR 

maternal* OR neonat* OR perinatal* OR pregnan* OR 

prenatal*):ti

#3 Combine sets #1 OR #2

#4 Population (women with a 

history of bariatric 

surgery)

'bariatric surgery'/exp OR 'gastric bypass surgery'/de OR 

gastrojejunostomy/de OR gastroplasty/de 
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 125 of 147

Question/Hedge Set # Concept Strategy

Question 3 – 

Nutritional 

Interventions 

for Pregnant 

Women Who 

Have Had 

Bariatric Surgery 

(cont.)

#5 (bariatric OR 'metabolic surgery' OR biliopancreatic OR

'bilio-pancreatic' OR 'duodenal switch' OR 'gastric 

balloon' OR (gastric NEXT/1 band*) OR 'gastric bypass' OR 

(gastric NEXT/1 sleeve*) OR gastroplast* OR 'jejunoileal 

bypass' OR lapband OR 'lap-band' OR 'obesity surgery' OR 

'Roux-en-Y' OR 'sleeve gastrectomy' OR 'stomach 

stapling' OR 'weight loss surgery'):ti

#6 Combine sets #4 OR #5

#7 Combine population and 

subpopulation sets

#3 AND #6

#8 Meta-analyses and 

systematic reviews

See hedge at end of table

#9 Condition (nutritional 

disorders)

nutrition/exp OR 'nutritional disorder'/exp

#10 Specific nutrients (anem* OR deficien* OR macronutrient* OR malnutrition 

OR micronutrient* OR nutrient* OR nutrition* OR 

supplement* OR vitamin* OR B OR B12 OR calcium OR 

folate OR 'folic acid' OR iron):ti,ab

#11 Combine sets #9 OR #10

#12 Topic of special interest 

(care of diabetes 

screening in women who 

experience dumping 

syndrome) 

'dumping syndrome'/de OR (dumping NEXT/1 syndrome* 

OR 'gastric emptying'):ti,ab

#13 'pregnancy diabetes mellitus'/exp/mj OR 'gestational 

diabetes':ti OR ((pregnancy/mj OR maternal:ti OR 

pregnan*:ti) AND diabetes:ti)

#14 'glucose tolerance test'/exp/mj OR 'glucose challenge' OR 

'glucose tolerance' OR 'oral glucose' OR fasting

#15 Combine sets #12 OR #13 OR #14

#16 Combine population with 

meta-analysis, topic, and 

intervention sets

#7 AND (#8 OR #11 OR #15)

Question 4 – 

Comparative 

Accuracy, 

Clinical Utility, 

and Cost of 

Methods of 

Aneuploidy 

Screening

#1 Population (pregnant 

women)

'perinatal period'/de OR pregnancy/exp OR 'pregnant 

women'/de OR 'prenatal period'/de OR (antenatal OR 

maternal OR obstet* OR perinatal OR prenatal OR 

pregnan* OR trimester):ti,ab

#2 Population (fetuses) 'parameters concerning the fetus, newborn and 

pregnancy'/exp OR (fetal OR fetus* OR foetal OR 

foetus*):ti,ab

#3 Condition (aneuploidy) aneuploidy/exp OR 'down syndrome'/de OR trisomy/exp 

OR 'klinefelter syndrome'/de OR 'turner syndrome'/de 

OR (aneuploid* OR "down syndrome" OR "downs 

syndrome" OR klinefelter* OR trisom* OR turner*):ti,ab

#4 Combine sets (#1 OR #2) AND #3

#5 Intervention (cell-free 

fetal DNA testing)

'non invasive measurement'/de OR (cffDNA OR cellfree 

OR 'cell-free' OR 'fetal DNA' OR 'fetal nucleic acid' OR 

'fetal nucleic acids' OR 'foetal DNA' OR 'foetal nucleic 

acid' OR 'foetal nucleic acids' OR 'noninvasive prenatal' 

OR 'non-invasive prenatal' OR 'prenatal diagnosis'):ti,ab
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 126 of 147

Question/Hedge Set # Concept Strategy

Question 4 – 

Comparative 

Accuracy, 

Clinical Utility, 

and Cost of 

Methods of 

Aneuploidy 

Screening 

(cont.)

#6 Intervention (maternal 

serum, nuchal 

translucency, 

amniocentesis, and other 

tests)

amniocentesis/exp OR 'chorion villus sampling'/de OR 

'diagnostic test accuracy study'/de OR 'maternal serum 

screening'/de OR 'nuchal translucency measurement'/de 

OR 'prenatal diagnosis'/de OR 'prenatal screening'/de OR 

('nuchal fold' OR 'nuchal thickness' OR 'nuchal 

translucency' OR ultrasonography* OR ultrasound OR 

biochemical OR biomarker* OR marker* OR PAPP-A OR 

hCG OR AFP OR e3 OR 'inhibin A' OR 'double test' OR 'triple 

test' OR 'quadruple test' OR 'combined test' OR 

amniocentesis OR 'chorionic villus'):ti,ab OR (screen* OR 

test*):ti

#7 Topic of special interest ((advanced OR anatomy OR anomaly OR detailed OR 

‘level II’ OR ‘level 2’ OR ‘second trimester’ OR targeted) 

NEXT/3 (scan OR scans OR sonogram OR sonograms OR 

ultrasonography OR ultrasound*)):ti,ab

#8 Combine sets #4 AND (#5 OR #6 OR #7)

Question 5 – 

Perinatal 

Screens for 

Psychiatric and 

Substance Use 

Disorders 

Compared with 

Routine 

Screening 

Methods

#1 Population (pregnant 

women)

'perinatal care'/de OR 'perinatal period'/de OR 

pregnancy/exp OR 'pregnant women'/de OR 'prenatal 

care'/de OR 'prenatal period'/de OR (antenatal OR 

antepartum OR maternal OR obstet* OR perinatal OR 

post-natal OR postnatal OR post-partum OR postpartum 

OR pre-natal OR prenatal OR pregnan*):ti

#2 Intervention (specific 

perinatal surveys and 

other routine surveys)

(T-ACE OR TWEAK OR '4-Ps plus' OR '4-P plus' OR '4P plus' 

OR '4Ps plus' OR (NET AND (alcohol OR drinker OR 

drinking)) OR EPDS* OR 'edinburg postnatal depression 

scale' OR PDSS OR 'postpartum depression screening 

scale' OR (AUDIT AND alcohol*) OR 'alcohol use disorders 

identification test' OR PHQ9 OR PHQ OR 'patient health 

questionnaire' OR C-BIAP OR GAD7 OR GAD-7 OR TACER3 

OR TACER-3):ti

#3 Intervention (laboratory 

tests and general testing 

concepts)

'drug analysis'/exp/mj OR 'drug urine level'/mj OR 

'laboratory diagnosis'/mj OR urinalysis/mj OR 'diagnostic 

accuracy'/mj OR 'diagnostic error'/mj OR 'diagnostic 

test'/mj OR 'mental disease assessment'/exp/mj OR 

'psychiatric diagnosis'/mj OR 'self report'/mj OR (assess* 

OR bioanalysis OR checklist* OR detect* OR diagnos* OR 

index* OR indices OR instrument* OR inventories OR 

inventory OR measure* OR profile* OR questionnaire* OR 

scale OR screen* OR (self NEXT/1 report*) OR survey* OR 

test OR tests OR tested OR testing OR tool*):ti

#4 Condition (psychiatric 

disorder)

'mental disease'/de OR (((mental* OR psychiatric) NEXT/1 

(condition* OR disease* OR disorder* OR health OR ill OR 

illness*)) OR ((anxiety OR behavior* OR behavior* OR 

mood) NEXT/1 disorder*) OR bipolar OR depress*):ti

#5 Condition (substance use 

disorder)

addiction/de OR 'drug abuse'/de OR 'drug 

dependence'/exp OR 'substance abuse'/de OR (addict* 

OR dependen* OR 'drug abuse' OR 'drug exposure' OR 

'drug use' OR illicit OR 'substance abuse' OR 'substance 

use' OR alcohol OR amphetamine* OR cocaine OR heroin 

OR marijuana OR methadone OR morphine OR opiate* 

OR opioid*):ti

#6 Combine sets #3 AND (#4 OR #5)

#7 Combine sets #1 AND (#2 OR #6)
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Question/Hedge Set # Concept Strategy

Question 6 – 

First Trimester 

Ultrasound to 

Establish or 

Confirm 

Gestational Age

#1 Pregnancy dating/ 

establishing gestational 

age

(gestational age dating' OR 'pregnancy dating' OR 

'trimester dating'):ti,ab

#2 ((delivery OR due OR pregnancy) NEAR/2 date):ti

#3 ((fetal OR foetal OR fetus OR foetus OR gestational) 

NEAR/2 age):ti

#4 'gestational age'/mj AND (accura* OR adjust* OR agree* 

OR assess* OR calculat* OR confirm* OR determin* OR 

discrepan* OR establish* OR estimate* OR measur* OR 

predict*):ti

#5 Combine sets #1 OR #2 OR #3 OR #4

#6 Intervention (ultrasound) ultrasound/de OR 'fetus echography'/exp OR echograph* 

OR sonogra* OR ultrasonograph* OR ultrasound* OR 

US:ti

#7 Combine sets (#5 AND #6) OR 'ultrasound dating':ti,ab

Question 7 – 

Factors or 

Interventions 

That Improve 

Outcomes 

Related to 

Breastfeeding

#1 Population (pregnant 

women/women receiving 

prenatal care)

'perinatal care'/de OR 'perinatal period'/de OR 

pregnancy/exp OR 'pregnant women'/de OR 'prenatal 

care'/de OR 'prenatal period'/de OR (antenatal OR 

obstet* OR perinatal OR prenatal OR pregnan*):ti

#2 Topic (breastfeeding) 'breast feeding'/exp/mj OR ('breast feeding' OR 

breastfeeding):ti

#3 Combine sets #1 AND #2

#4 Intervention (breast 

examination)

'breast examination'/de OR (breast NEXT/1 exam*):ti

#5 Intervention (formal 

education programs)

'breast feeding education'/exp OR education/de OR 

'health education'/de OR 'childbirth education'/de OR 

'health promotion'/de OR 'lactation consultant'/de OR 

'nutrition education'/de OR 'parenting education'/de OR 

'patient education'/de OR 'program evaluation'/exp OR 

(class* OR course* OR educat* OR program*):ti

#6 Intervention (experience, 

preparation, promotion)

(attitud* OR consult* OR determinant* OR duration* OR 

encourag* OR experienc* OR guidance OR improv* OR 

initiat* OR knowledg* OR likel* OR prepar* OR promot* 

OR provider* OR success* OR support* OR train*):ti

#7 Combine intervention sets #4 OR #5 OR #6

#8 Combine population, 

topic, and intervention 

sets

#3 AND #7

#9 Reoccurring concept (breastfeeding OR 'breast feeding'):ti AND initiat*:ti

#10 Combine sets #8 OR #9
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Question/Hedge Set # Concept Strategy

Question 8 – 

Impact of 

Exercise 

Frequency, 

Type, and 

Intensity on 

Maternal and 

Fetal Outcomes

#1 Population (pregnant 

women)

'perinatal care'/de OR 'perinatal period'/de OR 

pregnancy/exp OR 'pregnant women'/de OR 'prenatal 

care'/de OR 'prenatal period'/de OR (antenatal OR 

maternal OR obstet* OR perinatal OR prenatal OR 

pregnan*):ti

#2 Population (fetuses) 'parameters concerning the fetus, newborn and 

pregnancy'/exp OR (fetal OR fetus* OR foetal OR 

foetus*):ti

#3 Issue (formal exercise) exercise/exp/mj OR 'physical activity'/exp/mj OR 

sport/exp/mj OR (aerobic* OR athletic* OR aquatic* OR 

bicycling OR cycling OR dancing OR exercis* OR fitness OR 

hiking OR jogging OR running OR sports OR swimming OR 

walking OR yoga OR (physical NEXT/1 activit*)):ti

#4 Combine sets (#1 OR #2) AND #3

Question 9 – 

Pregnancyrelated 

Complications 

and Risk of 

Adverse LifeTime Health 

Outcomes

#1 Population (pregnant 

women)

'perinatal care'/de OR 'perinatal period'/de OR 

pregnancy/exp OR 'pregnant women'/de OR 'prenatal 

care'/de OR 'prenatal period'/de OR (antenatal OR 

maternal OR obstet* OR perinatal OR prenatal OR 

pregnan*):ti

#2 Issue (specific pregnancy 

complications)

'pregnancy diabetes mellitus'/exp/mj OR 'eclampsia and 

preeclampsia'/mj OR preeclampsia/mj OR 'maternal 

hypertension'/de OR ('gestational diabetes' OR 'preeclampsia' OR preeclampsia OR eclampsia):ti OR 

((gestational OR maternal OR pregnancy) AND 

hypertensi*):ti

#3 Combine sets #1 AND #2

#4 Issue (adverse life-time 

health outcomes) 

'cardiovascular risk'/exp/mj OR 'chronic disease'/de OR 

'life expectancy'/de OR lifespan/de

#5 (later NEXT/2 life):ti,ab OR (years AND (after OR 'followup' OR followup OR later OR 'post-partum' OR 

postpartum)):ti OR (chronic OR course OR decade* OR 

future OR later OR 'life expectancy' OR 'life-long' OR 

lifelong OR 'life-span' OR lifespan OR 'life-time' OR 

lifetime OR 'long term' OR longterm OR subsequent):ti

#6 Combine sets #4 OR #5

#7 Combine population, 

complications, and 

adverse outcomes sets

#3 AND #6

Question 10 –

Maternal Age &

Gestational Age 

and 

Consideration 

for Antepartum 

Surveillance and 

Planned 

Delivery

#1 Population (pregnant 

women)

'perinatal period'/de OR pregnancy/exp OR 'pregnant 

women'/de OR 'prenatal period'/de OR (antenatal OR 

antepartum OR maternal OR obstet* OR perinatal OR 

prenatal OR pregnan* OR trimester*):ti,ab

#2 Population (advanced 

maternal age)

'maternal age'/mj OR (40s OR forties OR older OR (middle 

NEXT/1 age*) OR (advanc* NEXT/2 age) OR ((35 OR 40 OR 

50) NEAR/3 (age* OR old* OR year*))):ti

#3 Combine sets #1 AND #2
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Question/Hedge Set # Concept Strategy

Question 10 – 

Maternal Age 

and Gestational 

Age and 

Consideration 

for Antepartum 

Surveillance and 

Planned 

Delivery (cont.)

#4 Intervention (antepartum 

surveillance and planned 

delivery)

amniocentesis/exp OR 'chorion villus sampling'/de OR 

'blood pressure monitoring'/de OR 'diagnostic 

procedure'/exp OR echography/exp OR monitoring/de 

OR 'obstetric operation'/exp OR 'obstetric procedure'/de 

OR 'patient monitoring'/exp OR 'physiologic 

monitoring'/exp OR 'perinatal care'/exp OR 'prenatal 

care'/exp OR 'prenatal diagnosis'/de OR 'risk 

management'/de OR 'risk reduction'/de OR 

ultrasound/de OR 'uterine activity monitoring'/de OR 

(care OR induc* OR manag* OR monitor* OR plan* OR 

observ* OR schedul* OR sonogra* OR surveillance OR 

test OR tests OR tested OR testing OR ultrasound* OR 

ultrasonogra*):ti

#5 Intervention 

(identification of risk)

'fetus control'/exp OR 'fetus disease'/exp OR 'fetus 

mortality'/de OR 'fetus outcome'/de OR 'fetus risk'/de OR 

hypertension/de OR 'high risk infant'/de OR 'high risk 

patient'/de OR 'high risk population'/de OR 'high risk 

pregnancy'/de OR 'labor complication'/de OR 

'intermediate risk patient'/de OR 'intermediate risk 

population'/de OR 'maternal hypertension'/de OR 

'maternal morbidity'/de OR 'maternal mortality'/de OR 

miscarriage/de OR 'perinatal morbidity' OR 'perinatal 

mortality'/exp OR 'placenta disorder'/exp OR 'pregnancy 

complication'/exp OR 'pregnancy disorder'/de OR 

'pregnancy loss'/de OR 'pregnancy outcome'/de OR 

'pregnancy toxemia'/exp OR 'premature labor'/de OR 

risk/de OR 'risk assessment'/de OR 'risk factor'/de OR 

stillbirth/de OR (aneuploid* OR 'c-section' OR caesarean 

OR cesarean OR down* OR chromosom* OR 'gestational 

diabetes' OR 'high blood pressure' OR hypertensi* OR 

'low birth weight' OR miscarriage* OR placenta* OR 

multiple* OR 'pregnancy loss' OR prematur* OR preterm 

OR risk* OR trisom* OR twin OR twins):ti

#6 Combine sets #3 AND (#4 OR #5)

General Hedges 

Applied to Each 

Search

Limit to humans and 

newly added publications

AND ([humans]/lim OR [article in press]/lim OR [in 

process]/lim)

Exclude lingering animal 

studies

NOT (mouse OR mice OR rabbit* OR rat OR rats OR sheep 

OR swine):ti

Limit to English language 

publications and to results 

with abstracts

AND [English]/lim AND [abstracts]/lim

Remove undesired 

publication types (e.g., 

conferences, editorials)

NOT ('conference paper'/exp OR ('case report' OR book 

OR editorial OR erratum OR letter OR note OR 'short 

survey')/de OR (book OR conference OR editorial OR 

erratum OR letter OR note OR 'short survey'):it OR 'year 

old':ti,ab OR (book OR 'conference proceeding'):pt OR 

comment:ti)

Limit by publication year AND [2008-2017]/py
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March 2018 Page 130 of 147

Question/Hedge Set # Concept Strategy

Study Type 

Hedges Applied 

as Needed (per 

Key Question 

Specific Criteria 

provided earlier 

in this report)

Limit to meta-analyses 

and systematic reviews

AND (('meta analysis' OR 'systematic review')/de OR 

('meta analysis' OR 'meta analytic' OR metaanaly* OR 

'research synthesis' OR 'systematic review' OR pooled OR 

pooling OR search*):ti,ab OR ('critical review' OR 

'evidence based'):ti OR cochrane:jt)

Limit to randomized 

controlled trials

AND ('random sample'/de OR 'randomized controlled 

trial'/de OR 'randomized controlled trial (topic)'/de OR 

randomization/de OR random*:ti,ab)

Limit to controlled clinical 

trials/comparative studies

AND (('comparative study'/exp OR 'controlled study'/exp) 

OR ('case control' OR compar* OR 'control group' OR 

'controlled study' OR 'controlled trial' OR 'cross over' OR 

crossover OR 'double blind' OR 'double blinded' OR 

'matched controls' OR placebo* OR random* OR 

sham):ti,ab OR (versus OR vs):ti)

Limit to cost-effectiveness 

analyses and other studies 

that address cost

AND (cost/exp OR 'economic evaluation'/exp OR 'health 

care cost'/exp OR cost*:ti,ab OR (afford* OR dollar* OR 

economic* OR expens* OR insur* OR paid OR pay* OR 

provider* OR save* OR saving* OR spend* OR spent):ti)

Limit to cohort studies AND ('cohort analysis'/de OR 'diagnostic test accuracy 

study'/de OR 'longitudinal study'/de OR 'prospective 

study'/de OR (cohort OR longitudinal OR 

prospective):ti,ab)

Limit to studies reporting 

validity, sensitivity and 

specificity, clinical utility

AND (‘diagnostic accuracy’/de OR ‘diagnostic test 

accuracy study’/de OR ‘diagnostic value’/de OR error/exp 

OR ‘major clinical study’/de OR ‘quality control’/exp OR 

‘predictive value’/de OR ‘receiver operating 

characteristic’/de OR ‘sensitivity and specificity’ OR 

‘validation study’/de OR validity/exp OR ((false OR true) 

NEXT/1 (negative* OR positive*)):ti,ab OR (accuracy OR 

accurate* OR ‘predictive value’ OR ROC OR ‘receiver 

operating characteristic’ OR sensitivity OR specificity OR 

validity OR variab* OR utility):ti,ab)
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Table F-4. PsycINFO (presented in OVID syntax)

Question Set # Concept Strategy

Question 5 – 

Perinatal 

Screens for 

Psychiatric 

and Substance 

Use Disorders 

Compared 

with Routine 

Screening 

Methods

#1 Population (pregnant 

women)

adolescent pregnancy/ OR pregnancy/ OR antepartum 

period/ OR perinatal period/ OR prenatal care/ OR postnatal 

period/ OR (antenatal OR antepartum OR maternal OR 

obstet* OR perinatal OR post-natal OR postnatal OR postpartum OR postpartum OR pre-natal OR prenatal OR 

pregnan*).ti.

#2 Intervention (specific 

perinatal surveys and 

other routine surveys)

(T-ACE OR TWEAK OR "4-Ps plus" OR "4-P plus" OR "4P plus" 

OR "4Ps plus" OR (NET AND (alcohol OR drinker OR drinking)) 

OR EPDS* OR "edinburg postnatal depression scale" OR PDSS 

OR "postpartum depression screening scale" OR (AUDIT AND 

alcohol*) OR "alcohol use disorders identification test" OR 

PHQ9 OR PHQ OR "patient health questionnaire" OR C-BIAP 

OR GAD7 OR GAD-7 OR TACER3 OR TACER-3).ti.

#3 Intervention (any survey 

or biologic screening 

test for psychiatric or 

substance use 

disorders)

"drug usage screening"/ OR urinalysis/ OR psychological 

assessment/ OR "self-report"/ OR (assess* OR bioanalysis OR 

checklist* OR detect* OR diagnos* OR index* OR indices OR 

instrument* OR inventories OR inventory OR measure* OR 

profile* OR questionnaire* OR scale OR screen* OR (self ADJ1 

report*) OR survey* OR test OR tests OR tested OR testing OR 

tool*).ti.

#4 Condition (psychiatric 

disorder)

exp affective disorders/ OR behavior disorders/ OR mental 

disorders/ OR (((mental* OR psychiatric) ADJ1 (condition* OR 

disease* OR disorder* OR health OR ill OR illness*)) OR 

((anxiety OR behavior* OR behavior* OR mood) ADJ1 

disorder*) OR bipolar OR depress*).ti.

#5 Condition (substance 

use disorder)

exp addiction/ OR exp drug abuse/ OR "substance use 

disorder"/ OR (addict* OR dependen* OR "drug abuse" OR 

"drug exposure" OR "drug use" OR illicit OR "substance 

abuse" OR "substance use" OR alcohol OR amphetamine* OR 

cocaine OR heroin OR marijuana OR methadone OR morphine 

OR opiate* OR opioid*).ti.

#6 Combine sets 3 AND (4 OR 5)

#7 Combine sets 1 AND (2 OR 6)

#8 Exclude animal studies 7 NOT (mouse OR mice OR rat OR rats OR rabbit* OR 

sheep).ti.

#9 Limit to English 

language publications

8 AND English.lg.

#10 Limit to results with 

abstracts

Limit 9 to abstracts

#11 Remove undesired 

publication types (e.g., 

case reports, 

comments)

10 NOT ((chapter OR "column/opinion" OR comment OR 

"comment/reply" OR dissertation OR editorial OR letter OR 

review-book).dt. OR (book OR encyclopedia OR "dissertation 

abstract").pt. OR "case report".ti,ab. OR "year-old".ti,ab.)

#12 Limit by publication 

year

limit #11 to yr=”2008 - -2017”

#13 Limit to meta-analyses 

and systematic reviews

12 AND (meta analysis/ OR ("meta analysis" OR "meta 

analytic" OR metaanaly* OR "research synthesis" OR 

"systematic review" OR pooled OR pooling OR search*).ti,ab. 

OR ("critical review" OR "evidence based").ti.)
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 132 of 147

Question Set # Concept Strategy

Question 5 –

Perinatal 

Screens for 

Psychiatric 

and Substance

Use Disorders 

Compared 

with Routine 

Screening 

Methods

(cont.)

#14 Limit to 

comparative/controlled 

studies

12 AND (random sampling/ OR ("case control" OR compar* 

OR "control group" OR "controlled study" OR "controlled 

trial" OR "cross over" OR crossover OR "double blind" OR 

"double blinded" OR "matched controls" OR placebo* OR 

random* OR sham).ti,ab. OR (versus OR vs).ti.)

#15 Combine sets 13 OR 14
VA/DoD Clinical Practice Guideline for the Management of Pregnancy

March 2018 Page 133 of 147

Appendix G: Abbreviation List

Abbreviation Definition

ACIP Advisory Committee on Immunization Practices

ACOG American Congress of Obstetricians and Gynecologists 

AHRQ Agency for Healthcare Research and Quality

AND Academy of Nutrition and Dietetics

AUDIT-C Alcohol Use Disorders Identification Test- Consumption

BMI body mass index

cffDNA cell-free fetal deoxyribonucleic acid

COI conflict of interest

COR contracting officer’s representative

CPG clinical practice guideline

CRS congenital rubella syndrome

CVD cardiovascular disease

CVS chorionic villus sampling

DoD Department of Defense

EBPWG Evidence-Based Practice Work Group

E-HITS Extended - Hurt, Insult, Threaten, Scream

EPDS Edinburgh Postnatal Depression Scale

FDA U.S. Food and Drug Administration

GBS Group B streptococcus

GDM gestational diabetes mellitus

GRADE Grading of Recommendations Assessment, Development and Evaluation

GTT glucose tolerance test

gm gram 

HbA1c glycosylated hemoglobin A1c

HSV herpes simplex virus

HPV human papillomavirus

IAP intrapartum antibiotics for prophylaxis

IOM Institute of Medicine

IPV intimate partner violence

KQ key question

lbs pounds

LMP last menstrual period

MCPAP Massachusetts Child Psychiatry Access Project

MDD major depressive disorder

mcg microgram(s)

MMR measles/mumps/rubella

MEDDAC U.S. Army Medical Department Activities

MSAFP maternal serum alpha-fetoprotein
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Abbreviation Definition

NAS neonatal abstinence exposure

NAM National Academy of Medicine

NET Normal drinker, Eye-opener, Tolerance

NDDG National Diabetes Data Group

NICE National Institute for Health and Care Excellence

NSDUH National Survey on Drug Use and Health

NTD neural tube defect

OEF Operation Enduring Freedom

OIF Operation Iraqi Freedom

Pap test Papanicolaou test

PCC patient-centered care

PHQ-9 9-item Patient Health Questionnaire

PICOTS population, intervention, comparison, outcome, timing and setting framework

PID pelvic inflammatory disease

PTSD posttraumatic stress disorder

RADIUS Routine Antenatal Diagnostic Imaging with Ultrasound

RCT randomized controlled trial

RDN Registered Dietitian Nutritionist

SDM shared decision making

SMFM Society for Maternal-Fetal Medicine

SR systematic review

SUD Substance use disorder(s)

TACE Tolerance, Annoyed, Cut down, Eye-opener

Td tetanus-diphtheria

Tdap tetanus, diphtheria, and pertussis

TORCH toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus (CMV), and 

herpes infections, are some of the most common infections associated with congenital anomalies

TWEAK Tolerance, Worried, Eye-opener, Amnesia,[K] Cut-down

U.S. United States

USPSTF U.S. Preventive Services Task Force

VA Department of Veterans Affairs

VHA Veterans Health Administration

VZV varicella zoster virus

VZIG VZV immune globulin

WHO World Health Organization
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March 2018 Page 135 of 147

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