MANAGEMENT GUIDELINES
Subject: Referral of High Risk Patients
Screening/Diagnosis:
These guidelines are meant to guide nursing staff in triaging patients. If conditions occur that are not included and/or have additional complications please consult with a Duke provider (CNM or MD 970-8033) to determine management for a specific patient.
Recommendations:
NEW PATIENTS
Patients should be referred directly to the Duke High Risk Obstetrics Clinic once pregnancy is confirmed if any of the following conditions are present at the time of registration.
Current Conditions
- Cardiac, renal, thyroid disease
- Diabetes mellitus
- +HIV
- Hypertension on medication
- Multiple gestation
- Substance abuse (drugs or alcohol not including marijuana)
- Active TB
- (patients with active TB can be seen in prenatal clinic and/or referred to High Risk Ob Clinic only after treatment and clearance by the County Health Department)
History
- Blood clot or clotting disorder including stroke, deep vein thrombosis, or other thromboembolic event
- Pretern loss <20 weeks (i.e. incompetent cervix) and/or h/o cerclage
- History of and/or risk for having an infant with a life threatening congenital disease
- Recurrent loss (3 or mor miscarriages)
- Organ transplant
- Preterm Birth
Patients with h/o preterm birth at between 20 and 36 weeks that was not related to maternal or fetal conditions (i.e. multiple births, fetal anomalies, or pre-eclampsia):
· Person, Franklin, or Warren County: refer patients to the high risk clinic Durham County Health Dept.: refer for a consultation visit in high risk ob clinic to determine plan of care including eligibility for 17 progesterone (17g). If 17pis appropriate it will be ordered and the patient will return in one week for their first injection. After that time the patient MAY be referred back to DCHD prenatal clinic if appropriate.
· Patients with a history of a still born infant should be referred to High Risk Ob Clinis for consultation visit(s) and plan of care AFTER their initialvisit. They will be referred back to their prenatal clinic if appropriate.
CONTINUNING PATIENTS
Patients should be referred to the Duke High Risk Clinic and/or Triage* using existing protocols, if any of the conditions above or if any of the following conditions below occur at any time during the prenatal period
- Gestational Diabetes
- Pathologic Hemoglobinopathies
- Lupus anticoagulant
- Multiple Gestations
- Pre-eclampsia*
- Preterm labor or significant contractions*
- Rh or other sensitization
- Severe anemia
- Unexplained abnormal maternal senim screen
Prepared in conjunction with the
Division of Maternal-Fetal Medicine
Duke University Medical Center
__________________________ ______
Director Date
5/08/08
References
Referral of High Risk Patients
1. Know AJ, Sadler L., Pattison NJ et al. An obstetric scoring system: Its development and application in obstetric management. Obstet Gynecol 1993, 81:195-199.
2. Nesbitt RE, Aubry RH. High risk obstetrics II value of semi-objective grading system in
Identifying the vulnerable group. Am J Obstet Gynecol 1969, 103: 972-985.
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