Pregnancy, a transformative phase, is significant for the individual and developing life. Due to health risks, it is necessary to provide careful medical supervision during this innate process. The Veterans Affairs (VA) and the Department of Defense (DoD) Clinical Practice Guideline offers best practice suggestions for managing pregnancy, focusing on VA, DoD, and community settings. It includes novel recommendations aligning care with individual health factors. Preventive care in pregnancy is covered, including COVID-19 vaccination and preeclampsia risk reduction. The guideline excludes detailed delivery management and alternative birthing options. It provides a foundation for prenatal and postpartum care enhancement for pregnant individuals in these contexts.1
Recommendations for Optimal Pregnancy Care1
Routine Care
Aneuploidy Screening
- It is recommended to prioritize non-invasive prenatal testing as the primary screening method for patients with singleton pregnancies seeking aneuploidy screening. (Strong recommendation | Reviewed, New addition)
- It is suggested to consider non-invasive prenatal testing for patients with twin pregnancies seeking aneuploidy screening. (Weak recommendation | Reviewed, New addition)
Lactation
- It is suggested that all patients undergo an assessment for risk factors affecting lactation initiation and continuation. These factors include obesity, depression, inappropriate gestational weight gain, and gestational diabetes mellitus. (Weak recommendation | Reviewed, New addition)
- It is suggested that individual or group lactation education be provided through in-person, telehealth, or multimedia formats to enhance the likelihood of successful lactation initiation and continuation among pregnant and postpartum patients. (Weak recommendation | Reviewed, Replaced)
Pelvic Floor Health
- It is suggested that all patients undergo an early prenatal evaluation of pelvic floor muscle function and receive instruction on pelvic floor muscle exercises during pregnancy. This approach aims to prevent urinary incontinence in late pregnancy and up to six months postpartum. (Weak recommendation | Reviewed, New addition)
- It is suggested that patients reporting urinary incontinence in the postpartum period be referred to pelvic health rehabilitation. (Weak recommendation | Reviewed, New addition)
Selected Conditions
- It is recommended to offer scheduled delivery to patients who have not delivered by 41 weeks and 0/7 days. Antepartum fetal testing should commence at this point if delivery has not occurred. (Strong recommendation | Not reviewed, Amended)
- It is suggested that patients with uncomplicated pregnancies may continue their standard work schedule throughout gestation. (Weak recommendation | Not reviewed, Amended)
- Telemedicine should be integrated as a supplementary component of routine perinatal care. (Weak recommendation | Reviewed, New addition)
- The evidence is insufficient to support or oppose specific interventions to reduce disparities in perinatal care access and maternal and childbirth outcomes. (Neither for nor against recommendation | Reviewed, New addition)
Mental Health
Screening
- It is recommended to screen for tobacco and nicotine products, alcohol, cannabis, illicit drugs, and inappropriate use of prescription medications. (Strong recommendation | Not reviewed, Amended)
- It is recommended to periodically screen for depression using standardized tools like the Edinburgh Postnatal Depression Scale or the 9-item Patient Health Questionnaire during pregnancy and postpartum. (Strong recommendation | Not reviewed, Unchanged)
- It is suggested that patients with posttraumatic stress disorder (PTSD) be screened for active PTSD and offered appropriate treatment. Referral to the VA/DoD PTSD CPG is advised for further guidance. (Weak recommendation | Reviewed, New addition)
Treatment
- It is recommended to offer individual or group Interpersonal Psychotherapy or cognitive behavioural therapy to pregnant patients at risk of perinatal depression. (Strong recommendation | Reviewed, New addition)
- It is recommended to offer Interpersonal Psychotherapy as a treatment option for depression during pregnancy or postpartum. (Strong recommendation | Reviewed, New addition)
- It is suggested to offer cognitive behavioural therapy as a treatment option for depression during pregnancy or postpartum. (Weak recommendation | Reviewed, New addition)
- It is suggested to offer peer support to individuals experiencing perinatal depression or at risk of perinatal depression to improve depressive symptoms. (Weak recommendation | Reviewed, New addition)
- It is suggested to consider exercise, mindfulness, yoga, or combinations thereof as interventions for addressing depressive symptoms in perinatal patients. (Weak recommendation | Reviewed, New addition)
- It is suggested to consider offering psychotherapies (e.g., cognitive behavioural therapy, Interpersonal Psychotherapy), yoga, or a combination of these interventions to manage anxiety symptoms during and after pregnancy. (Weak recommendation | Reviewed, New addition)
Conclusion
The management of pregnancy within the VA and DoD healthcare systems requires a multidimensional approach that accounts for individual patient needs, the evolving landscape of medical evidence, and the unique challenges pregnant individuals face. This comprehensive guideline, rooted in evidence-based recommendations, is a roadmap for healthcare professionals seeking optimal care for pregnant patients. By embracing patient-centred care, leveraging advanced methodologies, and remaining attentive to emerging trends, the VA/DoD Clinical Practice Guideline for the Management of Pregnancy contributes to the ongoing pursuit of improved maternal and infant health outcomes.
References
- Management of Pregnancy Work Group. VA/DoD Clinical Practice Guideline for the Management of Pregnancy. Washington, DC: US Government Printing Office 2023; 1-193. [Cited: August 21, 2023]. Available from: https://www.healthquality.va.gov/guidelines/WH/up/VA-DoD-CPG-Pregnancy-Full-CPG_508.pdf
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