ࡱ> QTJKLMNOPU Nbjbjnn aat|((&&&&&('('('(*$('"L/1.111V bufUWWWWWW$n${9&hkUVhh{&&11#2ppph&1&1UphUppj K17i/2A<"a>kdKK"&m ]hqhph hY]h]h]h{{n]h]h]h"hhhh]h]h]h]h]h]h]h]h]h(B j%: Prenatal Table of Contents (ctrl+click on text to go directly to section) CLINICAL PROTOCOLS  HYPERLINK \l "Matrix" Prenatal Services Matrix 1  HYPERLINK \l "Vitamins" Guidelines for Prenatal Vitamins 3-4  HYPERLINK \l "WeightGain" Recommendations for Weight Gain during Pregnancy 4-5 CASE MANAGEMENT  HYPERLINK \l "PRENATAL" Prenatal Lead Screening Guidelines 6  HYPERLINK \l "HepB" Hepatitis B 7  HYPERLINK \l "HepC" Hepatitis C 7  HYPERLINK \l "HIV" HIV Prevention of Perinatal Transmission 8 HYPERLINK \l "TRIPLESCREEN"Triple Screen/ Multiple Marker Test 9  HYPERLINK \l "CYSTIC" Cystic Fibrosis Screening . 9-10  HYPERLINK \l "GROUPB" Group B Streptococcus Screening .. 10  HYPERLINK \l "HERPES" Herpes Simplex Virus (HSV) 10-11  HYPERLINK \l "GLUCOSE" Glucose Testing Guidelines and Management for Gestational Diabetes Mellitus 12-14 HYPERLINK \l "Discomfort"Counseling Protocols for Common Discomforts 15-18 PRENATAL SERVICE GUIDELINES X= Required service; Services to be performed according to ACOG guidelines COMPONENT INITIAL WORKUP INITIAL EXAM RETURN VISITS 1520 WEEKS  2024 WEEKS 28 WEEKS32 WEEKS3537 WEEKSPOST-PARTUM VISITHISTORYComprehensive history (See ACOG Antepartum/Postpartum Forms)XReviewXAssess immunization statusXXLead Risk Assessment XAssess domestic violence/IPVXX-second trimesterX third trimesterXAssess depression/postpartum depressionXXXXXAssess for minor discomfortsXXXEXAMINATIONDetermine estimated date of confinementXXBlood pressure/Weight/BMIXXXXHeightXOral health screenwithin first trimesterComplete physical exam XXPelvic Exam (See Cancer Screening Section regarding Pap exams)XACOG Antepartum/Postpartum Forms XXXDocument fetal movement XXXLAB TESTS/PROCEDURESHgb/ HctX if indicated X Blood type/Rh FactorXRh antibody titerXif negPrenatal RhoGamif negHBsAg (see guidelines)X@ riskSyphilis IGGE (with reflex testing if +)X@ riskHIV (see guidelines)X@ riskRubella titerXBlood lead levels (see guidelines)If + screenBlood glucose (see guidelines)X@ risk@ 24-28 weeksIf had GDM GTT (see guidelines) If indicatedTriple Screen or Quad Screen (see guidelines)XUltrasoundX@ riskTB skin test@ riskDipstick urinalysisXXUrine culture (cc midstream)XPap testIf indicatedSee Cancer Screening sectionGonorrhea & Chlamydia & BV cultures@ risk@ riskCystic Fibrosis (see guidelines)Offer to allGBS vaginal culture (see guidelines)XCOUNSELING Nutrition/weight gain/vitamins/ folic acid & WIC Referral X  XBreastfeeding benefitsX XExerciseX (PN-3)Dental careXX@ riskSmoking, alcohol, & drug, SHS exposureXXXPaternity if indicatedPostpartum Blues/DepressionXXPreterm risk status/prevention/referralXXDomestic Violence/IPVX@ riskXHIV/AIDS & other prenatal testsXEnvironmental/work hazards/toxoplasmosisXMedication use (OTC & Rx)X XReferral to HANDSIf indicatedEnroll with PE/Medicaid/Emerg.MedicaidXIf applicableXProvide Pt with Education formsMCH, PN 3, 8, 11; PAM-ACH 263, 265; PN-2, PN-T1PN-T2PN-T3 PN-T4Anticipatory guidance by gestational age/ interests/risk factors  X X X History: Patients with a history of previous preterm birth/PPROM, or with a history of cervical incompetence/short, cervical length must be referred to an obstetrician prior to 18-20 weeks to be evaluated for possible use of progesterone to prevent preterm birth. Immunization Status: Every pregnant woman should be immunized appropriately if indicated. Influenza illness can cause complications in both mother and baby, so vaccine should be offered in season regardless of the stage of pregnancy. According to ACOG guidelines, pregnant women may receive vaccinations with an inactivated virus, bacterial vaccine, or toxoid; however, exposure to live vaccines should be avoided during pregnancy. Refer to the Immunizations Section for details. Prenatal Risk Assessment: Risk factors should be reviewed each trimester. ACOG recommends psychosocial screening on a regular basis to increase the likelihood of successful interventions. Screening should include assessment such as barriers to care, unstable housing, communication barriers, nutrition, tobacco use, substance use, depression, safety, intimate partner violence (IPV), and stress. These factors can contribute to risk of preterm birth, which should also be assessed. Domestic Violence (DV)/Intimate Partner Violence (IPV): Screening should be done by a health care provider who has been educated and trained in domestic violence and who is qualified to document in the medical record. Screening should be for current and past domestic violence that occurred anytime in a womans life. If a patient confides that she is being abused, verbatim accounts of the abuse should be recorded in the medical record and appropriate referrals made. The health care provider should inquire about her immediate safety and the safety of the children. Pelvic Exam/Pap Test: A pelvic exam should be completed on every pregnant woman at the initial prenatal exam regardless of whether a pap test is performed. If the patient is due a pap test according to the guidelines, she should provide documentation of her last pap test or else will need to have a pap test completed at the initial prenatal exam. Refer to the Cancer Screening Follow-Up Section for the list of guidelines to determine the need for a Pap test and proper follow-up. Nutrition/Weight Gain: The pregnant woman must be referred to Medical Nutrition Therapy (MNT) for low maternal weight gain, IUGR or oligohydramnios, BMI<18, eating disorders, lead poisoning, anemia, and excessive weight gain. Other conditions to consider referring include chronic disease, breastfeeding, HIV/AIDS, hyperemesis gravidarum, homelessness, multiple gestation, overweight, age <17 or >35, and weight loss during pregnancy. See chart of recommended weight gain during pregnancy. Folic Acid History must assess whether there is family history of NTD or other reason to require high dose folic acid clinician should be alerted to this need. Prenatal Vitamins: Vitamin supplementation should be prescribed/issued during pregnancy, the postpartum period, and the duration of breastfeeding and should meet the dietary reference intakes (see next page). This list is not all-inclusive and generically equivalent prenatal vitamin substitutes may be used. (Note: Prenatal vitamins may not be charged to the WIC program.) Medication use - Prenatal patients should be advised to consult with their health care provider before using nonprescription drugs or herbal remedies during pregnancy. All medications taken during the pregnancy including non-prescription meds, vitamins, and herbal supplements should be noted in the patient record. Alcohol, Tobacco, Other Drug Use (ATOD): All pregnant women should be screened at the first prenatal visit about their past and present use of alcohol, tobacco, secondhand smoke exposure and other drugs (ATOD), including recreational use of prescriptions and over-the-counter medications. This should be documented in the medical record and patients should be educated and referred appropriately. The Level I: Substance Use and Pregnancy Questionnaire (PN-2) has been renamed the Pregnancy Health Risk Screen. This is an optional evidence-based screening questionnaire specifically designed for pregnant women who are at risk for these behaviors. In addition to the ATOD screening, this questionnaire incorporates screening for domestic violence and maternal mental health issues with brief intervention guidelines, as well as suggested actions. GUIDELINES FOR PRENATAL VITAMINS 19972011 Dietary Reference Intakes (DRI)Minimum LevelMaximum LevelVitamin AAge < 18 750 mcg. RAE (3750 IU) Age 19 50 770 mcg. RAE (3850 IU)Age < 18 750 mcg. RAE (3750 IU) Age 19 50 770 mcg. RAE (3850 IU) Age < 18 2800 mcg. RAE (14,000 IU) Age 19 50 3000 mcg. RAE (15,000 IU)Vitamin D5 mcg. (200 IU)5 mcg. (200 IU)100 mcg. (4000 IU)Vitamin E15 mg. (10 IU)10 mg. (7 IU) Age < 18 800 mg. (536 IU) Age 19 50 1000 mg. (670 IU)Vitamin K75 mg (age <18) 90 mg (ages 19-50)NAAscorbic Acid/ Vitamin C Age < 18 80 mg. Age 19 50 85 mg.70 mg.Age < 18 1800 mg. Age 19 50 2000 mg.Thiamin1.4 mg.1.4 mg.NARiboflavin1.4 mg.1.4 mg.NANiacin18 mg.17 mg.Age < 18 30 mg. Age 19 50 35 mg.Vitamin B61.9 mg.2.0 mg.Age < 18 80 mg. Age 19 50 100 mg.Folic Acid*600 mcg.400 mcg.Age < 18 800 mcg. Age 19 50 1000 mcg.Vitamin B122.6 g.2.2 g.NABiotin30 mcg.AI of 30 mcg.NAPantothenic Acid6.0 mg.6.0 mg.NACalcium1300 mg. (age 1418) 1000 mg. (age 1950)250 mg.2500 mg. (age >18) 3,000 mg. (age <18)Choline4.5 g. (age <18) 4.5 g. (ages 19-50) 3.0 g. (age <18) 3.5 g. (ages 19-50)Copper1000 mcg.1000 mcg.8000 mcg.Iodine220 mcg.220 mcg.Age < 18 900 mcg. Age 19 50 1100 mcg.Iron27 mg.27 mg.45 mg.Magnesium400 mg. (age 1418) 350 mg. (age 1930) 360 mg. (age 3150)100 mg.350 mg.Molybdenum50 mcg,50 mcg,Age < 18 1700 mcg. Age 19 50 2000 mcg.Phosphorus Age < 18 1250 mg. Age 19 50 700 mg.Age < 18 1250 mg. Age 19 50 700 mg.3500 mg.Selenium60 mcg. 60 mcg.400 mcg.Zinc Age < 18 12 mg. Age 19 50 11 mg.9 mg.40 mg. (age >18) 34 mg. (age <18) NA = Not available NOTE: Remember that vitamins are tolerated best after a meal, so do not recommend on an empty stomach. *Any vitamin that contains 1 mg. or more of folic acid must be provided through a prescription. If a prenatal vitamin supplement will not meet all the guidelines established by the DRI, it is best to recommend a vitamin that would fall between the minimum and maximum levels and is approved by the prenatal provider. During the second trimester the prenatal supplement should contain at least the following: Iron 30 mg., Zinc 15 mg., Copper 2 mg., Calcium 250 mg., Vitamin B6 2 mg., Folic acid 300 mcg., Vitamin C 50 mg. and Vitamin D 5 mcg. LHDs should have a protocol for documenting the distribution of any medication, including vitamins. References: Nutrition Now, Judith E. Brown, University of Minnesota, 4nd edition, Wadsworth Publishing Company, Belmont, CA, 2005. Nutrition Through the Life Cycle, Judith E. Brown, et.al., University of Minnesota, 2nd edition, Wadsworth Publishing Company, Belmont, CA, 2005. Physician Desk Reference (PDR) 2005, 59th edition. Physician Desk Reference (PDR) for nonprescription drugs and dietary supplements 2004, 25th edition.  HYPERLINK "http://www.iom.edu/~/media/Files/Activity%20Files/Nutrition/DRIs/New%20Material/2_%20RDA%20and%20AI%20Values_Vitamin%20and%20Elements.pdf" http://www.iom.edu/~/media/Files/Activity%20Files/Nutrition/DRIs/New%20Material/2_%20RDA%20and%20AI%20Values_Vitamin%20and%20Elements.pdf  HYPERLINK "http://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx" http://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx  HYPERLINK "http://www.nap.edu/download.php?record_id=10872" http://www.nap.edu/download.php?record_id=10872  HYPERLINK "http://formularyjournal.modernmedicine.com/formulary-journal/RC/clinical/clinical-pharmacology/prenatal-vitamins-review-literature-benefits-a?page=full" http://formularyjournal.modernmedicine.com/formulary-journal/RC/clinical/clinical-pharmacology/prenatal-vitamins-review-literature-benefits-a?page=full RECOMMENDATIONS FOR WEIGHT GAIN DURING PREGNANCY1, 3 PREPREGNANCY BMI BMI (kg/m2)TOTAL WEIGHT GAIN (lbs) RATE OF WEIGHT GAIN 2nd AND 3rd TRIMESTERUnderweight*< 18.528401 (1 1.3)Normal Weight18.5 24.925351 (0.8 1)Overweight*25.0 29.915250.6 (0.5 0.7)Obese* (Includes All Classes)> 3011 200.5 (0.4 0.6)Twins2Normal Weight Status: 37 54# Overweight Status: 31 50# Obese Status: 25 43# *Poor weight gain can be a sign of poor fetal growth and must be evaluated by the medical provider. Any rapid weight gain (particularly after 24 weeks gestation) should also be evaluated by the medical provider. Determining appropriate weight gain is professional judgment that must be based upon the individual patients unique circumstances and weeks of gestation. * Refer to Medical Nutrition Therapy (MNT) if Underweight, Overweight, or Obese. Refer to MNT for excessive weight gain** or inadequate weight gain**. **Excessive weight gain = greater than eight pounds/month **Inadequate weight gain = less than two pounds/month after 1st trimester References: 1Weight Gain During Pregnancy, Reexamining The Guidelines, IOM, National Academy Press, Washington, DC, 2009. 2Nutrition During Pregnancy, Part I: Weight Gain, IOM, National Academy Press, Washington, DC, 1990. 3Weight gain during pregnancy. Committee Opinion No. 548. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:2102. BODY MASS INDEX (BMI)  All Pregnant WomenBody Mass Index (BMI) is a measure that can help determine if a person is at risk for a weight-related illness. To use this chart, find the height in the left-hand column.Move across the row until you find the weight. The number at the top of the column is the BMI.BMI1919.82021222324252626.127282929.13032343638404'10" (58")919596100105110115119124125129134138>1381431531621721811914'11"(59")949899104109114119124128129133138143>1431481581681781881985'(60")97102102107112118123128133134138143148>1481531631741841942045'1"(61")100105106111116122127132137138143148153>1531581691801902012115'2"(62")104108109115120126131136142143147153158>1581641751861962072185'3"(63")107112113118124130135141146147152158163>1631691801912032142255'4"(64")110116116122128134140145151152157163169>1691741861972092212325'5"(65")114119120126132138144150156157162168174>1741801922042162282405'6"(66")118123124130136142148155161162167173179>1791861982102232352475'7"(67")121127127134140146153159166167172178185>1851912042172302422555'8"(68")125130131138144151158164171172177184190>1901972102232362492625'9"(69")128134135142149155162169176177182189196>1962032162302432572705'10"(70")132138139146153160167174181182188195202>2022092222362502642785'11"(71")136142143150157165172179186187193200208>2082152292432572722866'(72")140146147154162169177184191192199206213>2132212352502652792946'1"(73")144150151159166174182189197198204212219>2192272422572722883026'2"(74")148154155163171179186194202203210218225>2252332492642802953116'3"(75")152158160168176184192200208208216224232>2322402562712873033196'4"(76")156162164172180189197205213214221230238>2382462622792953123286'5" (77)160166168176185193202210218219227235244>2442522692863033193366'6" (78")164170172181190198207216224225233241250>250259276293310328345 Adapted from the CDC Body Mass Index Table and the Institute of Medicine: Nutrition During Pregnancy, National Academy Press, 1990, page 12.Underweight = BMI < 19.8Normal = BMI 19.8 26.0Overweight = BMI 26.1 29.0Obese = BMI > 29.1 PRENATAL LEAD SCREENING GUIDELINES A. Risks of lead exposure in pregnancy Lead is a naturally occurring toxic element that can cause devastating fetal effects. Lead crosses the placental barrier and the developing nervous system of the fetus is particularly vulnerable to lead toxicity. Some studies have shown that blood lead levels as low as 5 ug/dL may result in adverse pregnancy outcomes including spontaneous abortion, premature birth, stillbirth, birth defects, and decreased intellect and/or behavior problems in the child. A special concern for pregnant women is that past bone lead accumulation may be released into the blood during pregnancy. Studies have also shown that males exposed to lead may have decreased sperm counts and/or abnormal sperm morphology. B. Patient assessment and education All prenatal patients shall be assessed for potential lead poisoning at the initial prenatal work-up visit and be given the PAM-ACH-25. The need for blood testing is based on a yes response to one or more lead risk assessment questions. The questions to determine risk status have been incorporated into the patient handout What is Lead? (PAM-ACH-25), that is available on the DPH website. Indications for blood testing If a prenatal patient answers yes to one or more of the four risk assessment questions at the initial visit, a venous blood specimen should be drawn the same day. A purple top tube should be drawn immediately and sent for analysis. This blood test should be drawn at the same time as the other prenatal lab work. D. Results of screening test: Level 5 - 14.9 ug/dLLevel > 15 ug/DlLead ExposureLead PoisoningA. Home visit and counseling to reduce or eliminate known risk factorsA. Home visit and counseling to reduce or eliminate known risk factorsB. Notify delivering physician of test results and repeat blood specimen in 8 weeksB. Notify delivering physician of test results and repeat blood specimen in 8 weeksC. At-risk Prenatal Patients should be followed up by case managementC. At-risk Prenatal Patients should be followed up by case managementRefer women for an environmental risk assessment*Guidelines for home visits, case management, and environmental risk assessments should be referenced from the Lead section. Documentation: Documentation in the medical record should be brief such as PAM-ACH-25 provided and discussed with no risk factors found or PAM-ACH-25 provided and discussed and blood to lab for screening due to positive risk factors. Any further interventions should also be documented in the patients medical record. Environmental and Clinical Health should work together on all prenatal cases of lead exposure or lead poisoning. Time to correct the problem is very limited and critical in preventing poor pregnancy outcomes. Pregnant women with lead levels above 5 ug/dL should be advised that any children in the household (ages 6 months6 years) should be referred to the LHDs Well-Child/EPSDT program or to their primary care provider for lead screening. Hepatitis B in pregnancy Pregnant women must be screened for Hepatitis B Surface Antigen during each pregnancy, at the initial prenatal visit. If the woman is high risk for contracting hepatitis B, the serological testing should be repeated in the last trimester. Negative Test and vaccination in pregnancy Any pregnant woman with a negative HBsAg who is at risk for developing hepatitis B infection should receive the vaccine as soon as possible. The vaccine is purified surface antigen and poses no known risk to the fetus. See IHYPERLINK "../../../TrinaM.Miller/AppData/Local/Microsoft/Windows/Temporary Internet Files/maryj.mullins/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.Outlook/AppData/Local/Microsoft/Windows/Documents and Settings/Trina.Douglass/Local Settings/Temporary Internet Files/OLK5/Immunizations.doc" \l "Protocols" \o "immunization protocols"mmunization protocols for specific information on vaccine administration. Positive test see Immunization section for reporting, management, and required tracking of mother and infant. HEPATITIS C IN PREGNANCY Hepatitis C (HCV) is a viral infection that is spread by direct contact with infected blood. An infected person may or may not have symptoms. Pregnant women with HCV infection should be referred to a subspecialist for further evaluation and management. Routine prenatal screening is not recommended except for women with the following risk factors for HCV infection: Health care, emergency medical and public safety personnel after a needle-stick injury or mucosal infection History of long-term hemodialysis Persons with persistently elevated alanine transferase levels or other evidence of liver disease Received blood products before 1987 or from a donor who later tested positive for HCV; received transfusions or organ transplants, particularly if received before July 1992 Use of illegal intravenous or intranasal drugs History of receipt of unregulated tattoos or body piercings Consider screening for patients with: Current sex partner infected with HCV History of HIV A baby can be infected during birth if the mother has HCV infection. There are no effective preventive measures to decrease the transmission of HCV from an infected mother to the baby during delivery. Pregnant women who are positive for HCV infection should be counseled that a cesarean delivery will not decrease the transmission of the HCV infection from her to the baby. Infants born to HCV-positive mothers should be tested for HCV infection at the routine well-child visit at two or four months with quantitative HCV RNA testing or at 18 months of age with HCV antibody testing. Women who are positive for HCV infection can still breastfeed but should consider abstaining from breastfeeding if their nipples are cracked or bleeding. References: ACOG Hepatitis B and Hepatitis C in Pregnancy FAQ 093.  HYPERLINK "http://www.acog.org/~/media/For%20Patients/faq093.pdf" http://www.acog.org/~/media/For%20Patients/faq093.pdf. Accessed May 28, 2015. CDC. Sexually Transmitted Diseases Treatment Guidelines, 2015. MMWR Recomm Rep 2015;64(3):19. American Academy of Pediatrics. Hepatitis C. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:423-430. PREVENTING PERINATAL HIV/AIDS TRANSMISSION A pregnant woman who receives prenatal care through the LHD shall be counseled on HIV, including identification of risk factors, and effective ways to reduce risks. Because of recent advances in both antiretroviral and obstetrical interventions, the use of antiretroviral medications during pregnancy and delivery, and to their newborns in the first few weeks of life, can reduce the vertical transmission rate from 25% to 2%. All pregnant women should be screened for HIV infection at the initial prenatal visit, is recommended regardless of risk factors. The PAM-ACH 263 or ACOG Patient Fact Sheet PFS005 should be provided on the initial prenatal visit and documented in the medical record. Repeat HIV testing in the third trimester, preferable before 36 weeks of gestation, is also recommended for women in areas where there is a high incidence or prevalence of HIV and also for women who are known to be at risk for acquiring HIV. Informed consent before testing is essential. Women shall be told they are being tested for HIV as part of the routine panel of prenatal tests unless they decline (Opt Out). Patient notification allows a woman to decline testing if she feels it is not in her best interest. Discussing and addressing reasons for refusal could promote health education and trust building and allow some women to accept testing at a later date. Documentation of informed consent shall use language the client understands. Pregnant women should be provided with verbal or written information about HIV, including interventions to reduce the risk of transmission from the mother to the infant. No additional written documentation of informed consent beyond that which is required for routine prenatal test is recommended. Refusal of the HIV test at the initial visit or at the recommended retesting time frame for those individuals at risk should also be documented in the medical record. For those women who have an established diagnosis of HIV, they should be linked to a specialist in HIV care for ongoing care and co-management. See HYPERLINK "../../../TrinaM.Miller/AppData/Local/Microsoft/Windows/Temporary Internet Files/maryj.mullins/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.Outlook/AppData/Local/Microsoft/Windows/Documents and Settings/Trina.Douglass/Local Settings/Temporary Internet Files/OLK5/HIV STD.doc" \o "HIV/AIDS Section"HIV/AIDS Section for further information and protocols. References: Prenatal and Perinatal Human Immunodeficiency Virus Testing: Expanded Recommendations. Committee Opinion 635. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015; 125:1544-7. Patient Fact Sheet available at:  HYPERLINK "http://www.acog.org/-/media/For-Patients/pfs005.pdf?dmc=1" http://www.acog.org/-/media/For-Patients/pfs005.pdf?dmc=1 MULTIPLE MARKER TEST (TRIPLE OR QUAD SCREEN) Maternal serum screening has become an important, non-invasive, diagnostic tool to screen for several congenital and chromosomal abnormalities. The Triple Screen measures alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and unconjugated estriol levels. If a fourth substance, Inhibin A, is added then it is called a Quadruple Screen. All prenatal clients should have the Triple Screen test performed between 15-20 weeks gestation. The most ideal screening time is between 16-18 weeks gestation. Patient counseling must emphasize that this is a screening test that will identify high-risk pregnancy. If the patient declines testing, documentation must be noted in the medical record. The Multiple Marker specimen must be submitted to a clinical laboratory that has normative data specific to each week of gestational age and is able to provide interpretation that considers maternal age, weight, race, and relevant history such as maternal diabetes and family history of NTD. Imprecise information may lead to inaccurate test results. An abnormal Multiple Marker Test result is NOT diagnostic of a fetal anomaly but does warrant further evaluation. DO NOT REPEAT THE TRIPLE SCREEN TEST IF YOU RECEIVE AN ABNORMAL RESULT. Refer for ultrasound to determine an identifiable cause. Incorrect EDC, multiple gestation, or fetal death may be the cause of the abnormal result as well as congenital anomalies. If the ultrasound confirms the presence of a congenital anomaly, the patient should be referred immediately to a physician who provides care for high-risk obstetrical patients. If the ultrasound fails to determine a cause of the abnormal Multiple Marker Test, the patient should be referred to an obstetrician for possible amniocentesis. Reference: Available at  HYPERLINK "http://www.acog.org/-/media/For-Patients/faq165.pdf?dmc=1&ts=20150512T0838463475" http://www.acog.org/-/media/For-Patients/faq165.pdf?dmc=1&ts=20150512T0838463475 CYSTIC FIBROSIS SCREENING Cystic Fibrosis (CF) is a genetic disorder caused by changes in a pair of CF genes and is usually diagnosed in the first few years of life. Cystic Fibrosis causes problems with digestion and breathing but does not affect intelligence or appearance. Both parents must be carriers for the baby to develop CF. There is a 25% chance with each pregnancy that the child will have CF if both parents are carriers. Most patients are not familiar with CF and will need to learn about it. Written educational material or other formats should be used to educate patients and partners. Counseling, regarding CF carrier testing, is usually done by the primary obstetric care provider. However, in some circumstances referral to a medical geneticist may be helpful. CF screening should be offered to all prenatal patients, although non-Hispanic white and Ashkenazi Jewish populations are at a higher risk. Newborn screening panels that include CF screening do not replace maternal carrier screening. If she has been previously screened for CF, the results should be documented but the test should not be repeated. Appropriate screening does NOT include complete analysis of the CFTR gene by DNA sequencing or a newborn screening panel that includes CF screening. If the moms CF screening test shows that she is a carrier, then the father of the baby should be offered testing. This test may be performed by the LHD or he may be referred to a provider for testing, but the LHD does not have to pay for this test and it should not be coded to cost center 803. If he is tested at the LHD, he should sign a consent form. Education and interventions should be documented. The provider may offer the pt additional testing during pregnancy, such as Chorionic villus sampling (generally done around the 11th week of pregnancy) and amniocentesis (generally done around the 16th week of pregnancy) to further determine if the baby has CF. Cystic Fibrosis is not a curable disease and there are no treatments available before the baby is born. However, there are treatments available after the baby is born. Couples can use the time prior to the birth to learn as much as possible about CF, current treatment options, and the experiences of families with CF children, or by talking to care providers. Documentation of the consent process is extremely important. A sample consent form in English and Spanish is available in the Forms Section. References: Update on carrier screening for cystic fibrosis. Committee Opinion No. 486. American College of Obstetricians and Gynecologists. ObstetGynecol 2011;117:102831. ACOG FAQ Guide available at  HYPERLINK "http://www.acog.org/Patients/FAQs/Cystic-Fibrosis-Prenatal-Screening-and-Diagnosis" http://www.acog.org/Patients/FAQs/Cystic-Fibrosis-Prenatal-Screening-and-Diagnosis PERINATAL GROUP B STREPTOCOCCUS SCREENING The adherence to the most current CDC algorithm for GBS screening is estimated to prevent approximately 90% of newborn Group B Streptococcus infections. All prenatal clients will be screened for Group B Streptococcus between 3537 weeks gestation. Clinicians should follow the most recent CDC/ACOG algorithms for management. Screening Method Swab the lower vagina (vaginal introitus), followed by the rectum (through the anal sphincter) using the same swab or two different swabs. Cervical, perianal, perirectal, perineal specimens are not acceptable. A speculum should not be used for culture collection. Place the swab(s) into a nonnutritive transport medium. Group B streptococci isolates can remain viable in transport media at room temperature for 1 day without a risk of false-negative test results. Specimen requisitions should clearly indicate the specimens are for group B streptococci culture. Laboratories performing these cultures should ensure clinicians have continuous access to results 24 hours per day/7 days per week. If group B streptococcal bacteruria is detected any time during the pregnancy, it should be treated. Reference: Prevention of early-onset group B streptococcal disease in newborns. Committee Opinion No. 485. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1019-27. HERPES SIMPLEX VIRUS (HSV) Couples should be educated about the natural history of genital HSV infection and should be advised that, if either partner is infected, they should abstain from sexual contact while lesions are present. To minimize the risk of transmission, use of condoms is recommended for asymptomatic HSV-infected individuals. Susceptible pregnant women should avoid sexual contact during the last eight weeks of pregnancy if their partners have active genital HSV infections. Prior to delivery, women with a history of genital HSV should be asked about recent symptoms and should undergo careful examination of the perineum. Cesarean delivery is indicated for all women with active (primary and recurrent) genital HSV lesions at the time of delivery. Reference: Available at  HYPERLINK "http://www.acog.org/-/media/For-Patients/faq054.pdf?dmc=1&ts=20150512T0902277409" http://www.acog.org/-/media/For-Patients/faq054.pdf?dmc=1&ts=20150512T0902277409 GLUCOSE TOLERANCE TESTING GUIDELINES AND MANAGEMENT FOR GESTATIONAL DIABETES MELLITUS (GDM) Purpose Gestational diabetes mellitus (GDM) is a condition that begins during pregnancy due to carbohydrate intolerance. GDM is one of the most common medical complications that occur during pregnancy. Women with GDM are at an increased risk of gestational hypertension, preeclampsia, cesarean delivery and possibly other potential morbidities. Infants born to mothers with GDM are at an increased risk of macrosomia, neonatal hypoglycemia, hyperbilrubinemia, shoulder dystocia and cesarean section. Screening According to the ACOG guidelines, all pregnant women should be screened for GDM, either by the patient medical history, clinical risk factors or laboratory test results. Screening is generally performed at the 24-28 week prenatal visit, but early screening is recommended in women with risk factors. Early screening for undiagnosed type 2 diabetes is also suggested in women with the following risk factors: A previous medical history of gestational diabetes mellitus A known impaired glucose metabolism Obesity ( BMI > 30) If GDM is not diagnosed, blood glucose testing should be repeated at the 24-28 weeks of gestation. Testing Procedures Diagnostic Testing Procedures The Glucose Challenge Test (GCT) is the screening test that consists of a 50-gram (commercially prepared) oral glucose load followed by a plasma or serum glucose sample determination one hour later. The glucose load is best tolerated when it is chilled and citrus rather than cola flavored (the glucose should be taken orally within 5 minutes). The patient does not need to be fasting for this test. If the one hour test is abnormal (>140-179 mg/dl), a 100 gram diagnostic Oral Glucose Tolerance Test (OGTT) is performed. (Do not proceed with 3 hour OGTT if 1-hour 50-gram load venous blood glucose is >180 mg/dlrefer to physician.) Schedule 3 hour OGTT within 7 days. The Oral Glucose Tolerance Test (OGTT) is the diagnostic test for GDM. It is recommended that the OGTT be performed in the morning after an overnight fast of at least 8 hours but no greater than 14 hours. At least 3 days of unrestricted diet (150 gram carbohydrate per day) and unrestricted activity (unless otherwise contraindicated) need to precede the test. Women taking prescription medication should check with their health care provider for specific instructions. Women need to remain seated and not smoke during the test. A finger stick blood (capillary) sample along with a fasting venous (plasma) blood sample should be obtained prior to the administration of the commercially prepared glucose solution. If the fasting finger stick blood level is greater than 126 mg/dl, do not administer oral glucose without consulting the patients provider. The patients provider should determine whether or not to proceed with the 3 hour OGTT. If the fasting finger stick blood level is below 126 mg/dl proceed with the test. Venous blood samples are then collected at one, two, and three hour intervals. Diagnosis According to ACOG guidelines, diagnosis of GDM can be determined by the result of a 100 Gram, 3 hour oral glucose tolerance test. Either the plasma or serum glucose level established by Carpenter and Coustan or the plasma level designated by the National Diabetes Data Group is appropriate to use. A definitive diagnosis of GDM requires that two or more thresholds be met are exceeded. Table 1. Diagnostic Criteria for the 100 gram, 3 hour Oral Glucose Tolerance Test (OGTT) for GDMStatusCarpenter and Coustan ConversionNational Diabetes Data Group ConversionPlasma or Serum Glucose LevelPlasma LevelFasting951051 Hour1801902 Hours1551653 Hours140145 A positive diagnosis requires that two or more thresholds are met or exceeded To make this test reliable, the patient must be fasting and administered a 100-gram commercially prepared solution.  Management of Diagnosed GDM Refer to physician for medical management and fetal surveillance. Refer to dietitian (RD/LD) or for Medical Nutrition Therapy. Counsel about GDM and the need for postpartum follow-up. Counsel about self-monitoring of blood glucose (SMBG) and daily fetal kick counts. (starting at 2632 weeks gestation) Home Blood Glucose Monitoring and Follow-up: CONTROLLEDUNCONTROLLEDFasting whole blood < 95 Fasting plasma <105 1 hr pp whole blood <140 1 hr pp plasma <155 2 hr pp whole blood <120 2 hr pp plasma <130 Continue current therapyFasting whole blood >95 Fasting plasma > 105 1 hr pp whole blood >140 1 hr pp plasma >155 2 hr pp whole blood > 120 2 hr pp plasma >130 Refer to physicianNote: Many blood glucose monitors now calibrate to plasma glucose. Values depend on the meter. GDM ASSESSMENT APPROPRIATE SCREENINGRESULTSMANAGEMENTAbnormal BG at initial prenatal visit: Fasting BG > 126 mg/dl Random (Casual) BG > 200 mg/dl Note: If a capillary specimen is performed, the blood glucose meter must yield a plasma equivalent value.Refer immediately for subsequent testing do not do further testingA fasting plasma glucose level > 126 mg/dl or a random (casual) plasma glucose > 200 mg/dl meets the threshold for the diagnosis of diabetes, if confirmed on a subsequent day unless unequivocal symptoms of hyperglycemia are present.As directed by a qualified physicianAll pregnant women should be screened for GDM Plasma glucose following a 1-hour 50 gm load prior to 20 weeks gestation<139 mg/dl 140179 mg/dl > 180 mg/dlRepeat at 2428 weeks gestation Schedule 3hr OGTT within 7 days Refer to a physician Repeat Screening at 2428 weeks gestation Perform 1-hour plasma glucose following a 50-gram load (See procedure)<139 mg/dl 140179 mg/dl >180mg/dlFurther testing not needed Schedule for 3hr OGTT within 7 days (See procedure) Refer to a physicianPostpartum screening for all women who had GDM Postpartum screening: (With Hx of recent GDM) Either a fasting plasma glucose, or a 2 hour OGTT performed at 612 weeks postpartum following deliveryNegative: <100mg/dl Positive: e"100mg/dl Repeat q 3 years or more often depending on risk factors or if symptoms develop Provide counseling & referral to physician & nutritionist References: ACOG Gestational Diabetes FAQ177 available at:  HYPERLINK "http://www.acog.org/Patients/FAQs/Gestational-Diabetes" http://www.acog.org/Patients/FAQs/Gestational-Diabetes Gestational diabetes mellitus. Practice Bulletin No. 137. American College of Obstetricians and Gynecologists. ( HYPERLINK "http://www.ncbi.nlm.nih.gov/pubmed/23969827" \o "Obstetrics and gynecology." Obstet Gynecol. 2013:406-16) COUNSELING & REFERRAL FOR COMMON DISCOMFORTS IN PREGNANCY DISCOMFORTPOSSIBLE CAUSENURSE ACTIONBackaches/Low Back Pain Possible sign of preterm labor Possible symptom of a urinary tract infection Normal lordosis of pregnancy caused by the enlarging uterus Improper body mechanics Normal relaxation of the pelvic joints Assess for symptoms of preterm labor/urinary tract infection Consult/refer to medical provider if preterm labor is suspected or symptoms of UTI Education: symptoms of preterm labor, proper body mechanics, prenatal exercises (pelvic tilt), avoid heels/ lifting, apply heat/ massage, firm mattress/proper rest, possible maternity girdle or sling for support.Bleeding Gums Possible sign of periodontal disease/gingivitis Increased estrogen during pregnancy Refer for dental evaluation if recurring Education: risk of preterm birth with untreated periodontal disease, proper oral hygiene with regular brushing, flossing, and rinsing with antiseptic mouth washBreast Tenderness Caused by increase in estrogen, progestins, vascularity, and glandular components of the breasts. Usually decreases or subsides after first trimester. Education: wear a well-fitting support bra, avoid breast stimulation, use lanolin to nipple area if needed, use clear water on the nipples and avoid use of soap. Constipation Common side effect from iron therapy Decreased motility of the gastro intestinal tract as a result of increase in progestin levels Decreased physical activity Inadequate roughage and fluids Increased pressure of the uterus on the bowelEducation: increase fluid intake and fiber in the diet (raw fruits, vegetables, whole grains), avoid laxatives (including mineral oil), increase foods with laxative effects such as prune juice, increase physical activity such as walking and establish regular bowel habits (following meal) Medical provider may suggest stool softener Edema Causes may include preeclampsia, protein deficiency, renal disease, or cardiac disease Increased venous pressure in the legs from the gravid uterus Increased capillary permeability Sodium and water retention from hormonal influences Increased dilatation of veins Assess signs of preeclampsia, if in the second or third trimester (including hypertension, proteinuria, rapid weight gain, generalized edema, brisk reflexes) Refer to provider if symptomatic of preeclampsia Refer to medical provider for symptoms of underlying disease Education: avoid excess salt (chips, pickles, canned foods, sodas) but do not recommend a low salt diet, increase fluid intake (water, juices), elevation of the lower extremities, increase rest (preferable left lateral position) Fainting (lightheaded, dizzy, vertigo)Common causes include anemia, hypoglycemia, hyperventilation, seizures, and dehydration. Decreased venous return Supine hypotension (Vena-Cava Syndrome) Pooling of blood in the lower extremities Eating disordersRefer to provider if accompanied by headaches, visual disturbances, an increase frequency and as otherwise indicated Obtain blood pressure, hemoglobin, blood glucose as indicated Assess diet for adequate calories and fluid intake Education: lay in a left lateral position (avoid supine position), avoid sudden postural changes, eat small frequent meals to avoid hypoglycemiaNasal stuffiness & Nosebleeds (epistaxis)Increase in hormones cause increase vascularity Increased dilation of capillaries in the skin and mucus membranes Most common in the 2nd trimester, return to normal following pregnancyRefer to medical provider if heavy nosebleeds or infection; check BP Education: avoid trauma such as hard blowing of the nose, avoid nasal sprays and decongestants, and may apply external gentle nasal pressure to stop the bleeding DISCOMFORTPOSSIBLE CAUSENURSE ACTIONHeadachesMay be a sign of preeclampsia in late second or third trimesters Other causes include hypoglycemia, migraines, dehydration, and illness Emotional tension/stress Nasal congestion from estrogen levels Increase in circulating blood volume Common in the first trimester due to increased hormone levelsAssess for signs of preeclampsia if 2nd or 3rd trimester of pregnancy Refer to medical provider if symptomatic Education: importance of adequate rest/sleep, adequate diet/fluid intake, avoid aspirin and ibuprofen products in pregnancy Heartburn and IndigestionCauses include vomiting, ulcers, hiatal hernia, gastric-esophageal reflux disease (GERD) Fatty food intolerance Stomach displacement and compression due to enlarging uterus Increase gastric reflux due to progesterone Decrease pepsin secretion due to estrogen elevations Emotional upsets/stressRefer to medical provider if underlying disease or persistent symptoms Education: eat small, frequent meals, eat slowly, avoid lying down after meals, avoid gas producing foods, sip on milk or herbal tea, avoid baking soda, eliminate greasy, spicy, fried foods from the diet, and clarify use of over the counter antacids (low sodium, high calcium). InsomniaContributing causes may include fetal movement*, heartburn, leg cramps, shortness of breath, caffeine, or apprehension Difficult positioning due to enlarged uterus Urinary frequency (nocturia) is a common contributing factor Inability to sleep usually occurs in the 3rd trimesterConsult/Refer to provider immediately if patient report decreased or no fetal movement. Educate the patient regarding kick counts Education: use pillows for support of back and between legs, avoid caffeine; increase activity; warm bath or shower, massage of back and neck, and avoid long day-time napping. Leg cramps/ painThrombophlebitis and varicosities Calcium/phosphorous imbalance Muscle strain/fatigue/ lack of exercise Blood vessel compression in legs Nerve compression in legs from the enlarging uterus Assess for redness, warmth, edema, positive Homans sign, or severe pain Refer to medical provider if symptomatic Education: avoid sodas and processed foods (very high in phosphorous), increase dietary calcium if needed; apply local heat; exercise such as walking (unless contraindicated), and avoid leg massage (may dislodge a clot if present)Skin changesStriae (stretch marks), spider angiomas, chloasma (mask of pregnancy), linea nigra, darkening of aerola, increased hair and fingernail growth, redness of the palms of the hands and soles of the feet Caused by increased production of estrogen and increase in circulationRefer to medical provider for rashes, allergic reaction, changes in moles, increased excoriation as indicated by patients history. Education: eliminate direct sunlight exposure and use sunscreen on exposed body parts. DISCOMFORTPOSSIBLE CAUSENURSE ACTIONVaginal DischargeAn increase in vaginal discharge over a short period of time may be a sign of impeding preterm labor Malodorous or colored discharge with or without itching are symptoms indicative of an infection Increase in estrogen levels during pregnancy results in an increase in cervical mucus production Increase in odorless, thin-mucoid, clear-white vaginal discharge is normal in pregnancyConsult/refer to medical provider if preterm labor is suspected Refer to medical provider for complaint of itching, burning, malodor, bloody, or colored discharge Education: daily personal hygiene, avoid douching or tampons, wear cotton panties, avoid feminine hygiene products, jeans, pantyhose and other tight fitting clothingNausea/Vomiting Hyperemesis GravidarumHyperemesis gravidarum - Extreme, excessive, and persistent vomiting in early pregnancy that may lead to dehydration and malnutrition. May be increased with hydatiform mole and multiple gestations Metabolic changes (possible reduction in vitamin B6 metabolism) Changes in hormonal balance, increase in estrogen primarily Decrease gastric motility Gastroesophogeal reflux Increase in gastric secretions Assess for symptoms of dehydration (dry mouth, decrease in tear production, muscle cramps, nausea/vomiting, heart palpitations, lightheadedness, weakness, decreased urine output, and poor skin turgor. Refer to a medical provider if intractable vomiting, signs of dehydration, fever, or significant weight loss Refer to medical provider if intractable vomiting, signs of dehydration, fever or significant weight loss. Refer for MNT is applicable, Education: Avoid overeating/eating on an empty stomach, fried, greasy, or spicy foods, cooking odors, smoking, and medications unless prescribed by the medical provider. Suggest small frequent high protein meals (68 per day) and drink fluids between meals instead of with meals. May also try dry toast, crackers, ginger ale, peppermints, and fresh fruit.PalpitationsIncrease in blood volume, cardiac output, and heart rate Awareness of a rapid heartbeat more common in pregnancy May be associated with cardiac disease Refer to medical provider if signs of cardiac disease (shortness of breath, irregular or weak pulse, hypertension, dilated neck veins, abnormal pulse pressure, edema, excess fatigue) Education: avoid caffeine and encourage stress reduction DISCOMFORTPOSSIBLE CAUSENURSE ACTIONPelvic PressurePossible sign of impending premature labor or urinary tract infection (UTI) Pressure of the enlarging uterus pull support ligaments Relaxation of joints Softening and separation of tissue and joints due to hormonal influence (separation of the symphysis pubis not uncommon) Most common in the 3rd trimester once engagement of the presenting part has occurredReport signs of preterm labor, limitation of locomotion, and/or severe or persistent discomfort to the medical provider Assess for symptoms of preterm labor Assess for UTI Education: rest in left lateral position with pillow support, frequent rest periods, and good body mechanics. Avoid prolonged standing/ sitting and lifting. Shortness of breathMay be caused by pulmonary cardiac disease May be a sign of a pulmonary embolus Tends to be on exertion (climbing stairs) Increased if patient is anemic, obese, or has multiple fetuses Expansion of diaphragm limited by the enlarging uterus Most frequently seen in the late 3rd trimesterRefer to medical provider if symptoms increase in severity or are accompanied by excess fatigue, severe anemia, chest pain, palpitations, or other symptoms of pulmonary or cardiac disease. Education: importance of smoking cessation and avoid second hand smoke, avoid overeating, exertion and fatigue, utilize an extra pillow or elevate the head of the bedVaricose Veins (Perineal Varicosities)May be present in the legs, vulva, and/or rectum; most common in 3rd trimester Increase in blood volume adds pressure on the venous circulation Stasis in lower extremities from the enlarging uterus Heredity predisposition Progestins cause relaxation of smooth muscles Inactivity and poor muscle tone Hemorrhoids may be caused by straining or heavy liftingReport symptoms of thrombophlebitis, severe pain, or worsening symptoms to medical provider Education: left lateral rest periods, sitz baths for hemorrhoids, wear maternity well-fitting girdle/ support elevate legs for varicosities, and elevate the foot of the bed (6 inches). 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xx INTRODUCTION TO PRENATAL CARE Kara.BaberCourtney, Casey (CHFS DPH)d                           ! " # $ % & ' ( ) * + , - . / 0 1 2 3 4 5 6 7 8 9 : ; < = > ? @ A B C D E F G H I J K L M N O P Q R S T U V W X Y Z [ \ ] ^ _ ` a b c d e f g h i j k l m n o p q r s t u v w x y z { | } ~  Oh+'0 , L X d p| INTRODUCTION TO PRENATAL CARE Kara.BaberNormalCourtney, Casey (CHFS DPH)2Microsoft Office Word@@ǯ@y&@y&՜.+,D՜.+,\ hp  Cabinet Health Serviceskf INTRODUCTION TO PRENATAL CARE Title 8@ _PID_HLINKSA+0K,http://www.ncbi.nlm.nih.gov/pubmed/23969827o1H7http://www.acog.org/Patients/FAQs/Gestational-Diabetes EQhttp://www.acog.org/-/media/For-Patients/faq054.pdf?dmc=1&ts=20150512T0902277409c:BShttp://www.acog.org/Patients/FAQs/Cystic-Fibrosis-Prenatal-Screening-and-Diagnosis ?Qhttp://www.acog.org/-/media/For-Patients/faq165.pdf?dmc=1&ts=20150512T0838463475E<:http://www.acog.org/-/media/For-Patients/pfs005.pdf?dmc=1-59&../../../TrinaM.Miller/AppData/Local/Microsoft/Windows/Temporary Internet Files/maryj.mullins/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.Outlook/AppData/Local/Microsoft/Windows/Documents and Settings/Trina.Douglass/Local Settings/Temporary Internet Files/OLK5/HIV STD.docvd64http://www.acog.org/~/media/For Patients/faq093.pdf2<3,../../../TrinaM.Miller/AppData/Local/Microsoft/Windows/Temporary Internet Files/maryj.mullins/AppData/Local/Microsoft/Windows/Temporary Internet Files/Content.Outlook/AppData/Local/Microsoft/Windows/Documents and Settings/Trina.Douglass/Local Settings/Temporary Internet Files/OLK5/Immunizations.doc Protocols5j0http://formularyjournal.modernmedicine.com/formulary-journal/RC/clinical/clinical-pharmacology/prenatal-vitamins-review-literature-benefits-a?page=full-0http://www.nap.edu/download.php?record_id=10872s)*Dhttp://www.iom.edu/Activities/Nutrition/SummaryDRIs/DRI-Tables.aspx6z'zhttp://www.iom.edu/~/media/Files/Activity Files/Nutrition/DRIs/New Material/2_ RDA and AI Values_Vitamin and Elements.pdfl|$ Discomfort}|!GLUCOSEfHERPESxeGROUPBynCYSTIC TRIPLESCREENhiHIVHepC HepB  PRENATALxy WeightGain VitaminspkMatrix  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdeghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./012345679:;<=>?ABCDEFGHIRSWVYX[\]^_`abcdefghijklmnopqRoot Entry Fп;AUData f1TableF6WordDocument SummaryInformation(8DocumentSummaryInformation8@(MsoDataStore п;Aп;A3A0YUYU4VF==2п;Aп;AItem  PropertiesCompObj rIA4KDGU0LCGQ==2 п;Aп;A "1.0" encoding="UTF-8" standalone="no"?> sion="1.0" encoding="UTF-8" standalone="no"?>DocumentLibraryF  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89qormDocumentLibraryFormDocumentLibraryForm2C0-5D75-4160-A93A-FE23E911A54D}" xml This value indicates the number of saves or revisions. 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