The Effects of Group Prenatal Care on Infant Birthweight and Maternal Well-Being: A Randomized Controlled Trial.

INTRODUCTION: Group prenatal care models have been in use in the USA for over 20 years and have shown benefits in reducing rates of preterm birth and low birth weight infants in high-risk civilian populations. Group prenatal care has been widely implemented at military treatment facilities, despite a lack of high-quality evidence for improved perinatal outcomes in this population. MATERIALS AND METHODS: In this randomized, controlled trial, 129 patients at a military treatment facility received either traditional one-on-one prenatal care or group prenatal care using the CenteringPregnancy model. CenteringPregnancy care was administered by certified nurse midwives and family medicine residents and faculty. The primary outcomes were infant birthweight appropriateness for gestational age, maternal anxiety (as measured by the State-Trait Anxiety Inventory) and depression (as measured by the Center for Epidemiologic Studies-Depression scale), and patient satisfaction (as measured by the Short-Form Patient Satisfaction Questionnaire). Infant birthweights were compared using Chi-square tests for the categorical variables of small for gestational age (SGA), appropriate for gestational age (AGA), or large for gestational age. Maternal mood and satisfaction scores were evaluated before, during, and after the intervention and analyzed using rank sum tests. Additional demographic and outcome data were collected directly from participants and extracted from patient records. RESULTS: Patients receiving group care were more likely to deliver an infant that was appropriate for gestational age, with an incidence ratio of 1.12 [CI = 1.01-1.25, p = 0.04]. Depression and anxiety levels remained similar between groups throughout the study. Satisfaction was similar between groups, though patients receiving group care reported higher satisfaction with the accessibility and convenience of their care at the study's end [p = 0.048]. There were no differences between groups in preterm births, maternal or neonatal morbidity, mode of delivery, maternal weight gain, or breastfeeding rates. CONCLUSIONS: Military parturients receiving group prenatal care in the CenteringPregnancy model were less likely to deliver an small for gestational age or large for gestational age newborn and were more likely to be satisfied with their access to care. Group prenatal care is well received by patients and may positively influence neonatal metabolic status.

First trimester bleeding.

Vaginal bleeding in the first trimester occurs in about one fourth of pregnancies. About one half of those who bleed will miscarry. Guarded reassurance and watchful waiting are appropriate if fetal heart sounds are detected, if the patient is medically stable, and if there is no adnexal mass or clinical sign of intraperitoneal bleeding. Discriminatory criteria using transvaginal ultrasonography and beta subunit of human chorionic gonadotropin testing aid in distinguishing among the many conditions of first trimester bleeding. Possible causes of bleeding include subchorionic hemorrhage, embryonic demise, anembryonic pregnancy, incomplete abortion, ectopic pregnancy, and gestational trophoblastic disease. When beta subunit of human chorionic gonadotropin reaches levels of 1,500 to 2,000 mIU per mL (1,500 to 2,000 IU per L), a normal pregnancy should exhibit a gestational sac by transvaginal ultrasonography. When the gestational sac is greater than 10 mm in diameter, a yolk sac must be present. A live embryo must exhibit cardiac activity when the crown-rump length is greater than 5 mm. In a normal pregnancy, beta subunit of human chorionic gonadotropin levels increase by 80 percent every 48 hours. The absence of any normal discriminatory findings is consistent with early pregnancy failure, but does not distinguish between ectopic pregnancy and failed intrauterine pregnancy. The presence of an adnexal mass or free pelvic fluid represents ectopic pregnancy until proven otherwise. Medical management with misoprostol is highly effective for early intrauterine pregnancy failure with the exception of gestational trophoblastic disease, which must be surgically evacuated. Expectant treatment is effective for many patients with incomplete abortion. Medical management with methotrexate is highly effective for properly selected patients with ectopic pregnancy. Follow-up after early pregnancy loss should include attention to future pregnancy planning, contraception, and psychological aspects of care.