Clinical Practice Guidelines Antenatal care - Module I

lifestyle

Page last updated: 02 April 2013

Tobacco smoking

NICE recommendation

At the first contact with the woman, discuss her smoking status, provide information about the risks of smoking to the unborn child and the hazards of exposure to second-hand smoke. Address any concerns she and her partner or family may have about stopping smoking.

Pregnant women should be informed about the specific risks of smoking during pregnancy (such as the risk of having a baby with low birth weight and preterm birth). The benefits of quitting at any stage should be emphasised.

Offer personalised information, advice and support on how to stop smoking. Encourage pregnant women to use local NHS Stop Smoking Services and the NHS pregnancy smoking helpline, by providing details on when, where and how to access them. Consider visiting pregnant women at home if it is difficult for them to attend specialist services.*

Monitor smoking status and offer smoking cessation advice, encouragement and support throughout the pregnancy and beyond.*

Discuss the risks and benefits of nicotine replacement therapy (NRT) with pregnant women who smoke, particularly those who do not wish to accept the offer of help from the NHS Stop Smoking Service. If a woman expresses a clear wish to receive NRT, use professional judgement when deciding whether to offer a prescription.*

Advise women using nicotine patches to remove them before going to bed.*

This supersedes NICE technology appraisal guidance 39 on NRT and bupropion.*

Women who are unable to quit smoking during pregnancy should be encouraged to reduce smoking. [B]

* Recommendation from the NICE public health guidance on smoking cessation (www.nice.org.uk/PH010).

Research questions

1. What are the maternal and perinatal outcomes associated with smoking in pregnancy? (No new studies identified)
2. Do smoking cessation programs lead to reduction in smoking rates for pregnant women and what are the characteristics of smoking cessation programs that are most effective in reducing smoking among pregnant women? (Informed Recommendation 24)
3. Do smoking cessation programs decrease perinatal mortality and morbidity? (No new studies identified)
4. What interventions assist women to quit smoking? (Informed Recommendation 24)
5. Is nicotine replacement therapy safe for pregnant women? (Informed Recommendation 25)
6. What are additional considerations for Aboriginal and Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of searches: October 2009; November 2010
Limits: English language
Publication dates for searches:
1. January 2003 – October 2009
2. January 2008 – November 2010
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Review findings

1. 6 level I studies were identified in the NICE review that indicated a significant association between smoking in pregnancy and adverse outcomes. No additional evidence was identified.
2. 1 level I study from NICE. See response to question 4.
3. 1 level 1 study from NICE.
4. 5 level I studies, 8 level II studies, 1 level III-3 study and 3 level IV studies examined the effectiveness of smoking cessation interventions and informed the narrative (note that these Guidelines discuss assessment rather than intervention). Of these, 2 level IV studies and 2 observational studies informed the narrative on smoking cessation among Aboriginal and Torres Strait Islander women.
5. 2 level I studies and 1 level II study supported the need for caution in considering NRT during pregnancy.
6. See Question 4.

EAC recommendations

23. At the first antenatal visit:
  • assess the woman’s smoking status and exposure to passive smoking;
  • give the woman and her partner information about the risks to the unborn baby associated with maternal smoking and passive smoking; and
  • if the woman smokes, emphasise the benefits of quitting as early as possible in the pregnancy and discuss any concerns she or her family may have about stopping smoking.
24. Offer women who smoke referral for smoking cessation interventions such as cognitive behavioural therapy.
25. If, after other options have been explored, a woman expresses a clear wish to use nicotine replacement therapy, discuss the risks and benefits with her.

Evidence supporting recommendations (see Section 10.4.5)

Recommendation 23 — Based on evidence from NICE.
Recommendation 24 — Berg et al 2008; Dennis & Kingston 2008; Lumley et al 2009; Stotts et al 2009
Recommendation 25— Lumley et al 2009; Oncken et al 2008; Smith et al 2006

Grading of evidence — Recommendation 23

Evidence base - A
Consistency - B
Clinical impact - A
Generalisablity - B
Applicability - B
Recommendation - A

Grading of evidence — Recommendation 24

Evidence base - A
Consistency - B
Clinical impact - A
Generalisablity - B
Applicability - B
Recommendation - B

Grading of evidence — Recommendation 25

Evidence base - A
Consistency - B
Clinical impact - A
Generalisablity - B
Applicability - B
Recommendation - B
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Alcohol

Consensus-based recommendations

Consensus-based recommendation xi is based on Guideline 4 in NHMRC (2009) Australian Guidelines to Reduce Health Risks from Drinking Alcohol. Canberra: National Health and Medical Research Council. The recommendation is based on systematic review of the literature but was not graded. Literature on prevalence of alcohol consumption and associated risks during pregnancy published subsequent to the NHMRC guidelines has not been reviewed.

xi. Advise women who are pregnant or planning a pregnancy that not drinking is the safest option as maternal alcohol consumption may adversely affect the developing fetus or breastfeeding baby.

Medicines

Consensus-based recommendations

Consensus-based recommendations xii and xiii are based on advice from the Therapeutic Goods Administration.
xii. Advise women that use of prescription and over-the-counter medicines should be limited to circumstances where the benefit outweighs the risk as few medicines have been established as safe to use in pregnancy.
xiii. Therapeutic Goods Administration Category A medicines have been established to be safe in pregnancy.

Nutritional supplements

NICE recommendation

Pregnant women should be informed that vitamin A supplementation (intake above 700 micrograms) might be teratogenic and should therefore be avoided. Pregnant women should be informed that liver and liver products may also contain high levels of vitamin A, and therefore consumption of these products should also be avoided. [C]

Pregnant women (and those intending to become pregnant) should be informed that dietary supplementation with folic acid, before conception and up to 12 weeks of gestation, reduces the risk of having a baby with neural tube defects (anencephaly, spina bifida). The recommended dose is 400 micrograms/day. [A]

Research questions

1. What dietary advice should be provided to pregnant women? (Informed narrative in section on weight and BMI)
2. What are the risks of vitamin and mineral supplementation in pregnancy? (Informed Recommendations 26, 27 and 28)
3. What are the benefits of vitamin supplementation in pregnancy? (Informed narrative)
4. What are the risks of complementary medicines in pregnancy? (Informed narrative)
5. What are the benefits of complementary therapies in pregnancy? (Informed narrative)
6. What are the additional considerations for Aboriginal and Torres Strait Islander women? (Informed narrative)

Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane
Date of search: March 2011
Limits: English language
Publication dates for search: January 2003 – March 2011

Review findings

1. 2 level I and 4 level II studies incorporated into narrative in chapter on weight and BMI.
2. 1 level I study for iron; 1 Level I, 1 Level II for vitamin A; 1 Level I for vitamin C; 1 Level I for vitamin C+E supported the NICE recommendations on iron and vitamin A.
3. 6 level II studies supported the use of multinutrients in women experiencing malnutrition. 1 level I study supported the NICE recommendation on folic acid supplementation. Dosage changed in line with Australian advice.
4. 2 level III-2 and 1 qualitative study informed the narrative.
5. 3 Level I and 2 Level II studies on acupuncture were identified. Back pain was deferred until the next Module.
6. 3 level III-2 studies informed the narrative.
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EAC recommendations

26. Inform women that dietary supplementation with folic acid, from 12 weeks before conception and throughout the first 12 weeks of pregnancy, reduces the risk of having a baby with a neural tube defect (for example, anencephaly or spina bifida) and recommend a dose of 500 micrograms per day.
27. Advise women that taking vitamins A, C or E supplements is not of benefit in pregnancy and may cause harm.
28. Do not routinely offer iron supplementation to women during pregnancy.

Evidence supporting recommendations (see Section 10.4.5)

Recommendation 26 — Bower et al 2004; 2009; De Regli et al 2010
Recommendation 27 — Kirkwood et al 2010; Rumbold & Crowther 2005; Rumbold et al 2011; van den Broek et al 2010; Xu et al 2010
Recommendation 28 — Reveiz et al 2007

Grading of evidence — Recommendation 26

Evidence base - A
Consistency - A
Clinical impact - C
Generalisablity - A
Applicability - A
Recommendation - A

Grading of evidence — Recommendation 27

Evidence base - A
Consistency - NA
Clinical impact - B
Generalisablity - A
Applicability - A
Recommendation - B

Grading of evidence — Recommendation 28

Evidence base - A
Consistency - NA
Clinical impact - B
Generalisablity - A
Applicability - A
Recommendation - B

Oral health

NICE recommendation

None

Research questions

1. Are there any dental procedures or treatments that are unsafe in pregnancy? (Informed narrative)
2. Does periodontal disease confer any risks to pregnancy or to the neonate? (Informed narrative)
3. Does dental caries confer any risks in pregnancy or to the neonate? (Informed narrative)
4. What is the optimal timing of screening for oral health? (No studies identified)
5. What information/education and advice should clinicians provide for women? (Informed Recommendation 29)
6. What are the additional considerations for Aboriginal and Torres Strait Islander women? (No studies identified)
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Search Strategy

Databases searched: Medline; Embase; Australasian Medical Index; ATSIhealth; Google Scholar; Cochrane Database
Date of search: November 2010
Limits: English language
Publication dates for search: January 2003 – November 2010

Review findings

1. 1 level II, 1 level III-1, 2 level III-2 and 1 level IV were inconsistent on the safety of dental treatments in pregnancy.
2. 1 level I, 8 level II, 7 level III-2, 9 level III-3 and 14 level IV suggested that periodontal disease does not confer risks to pregnancy and informed the narrative.
3. 2 level III-2 and 2 level IV studies were inconclusive on the risks of caries in pregnancy.
4. No studies identified.
5. 1 level II and 5 level IV highlighted the importance of women receiving advice on oral health during pregnancy.
6. No studies identified.

EAC recommendation

29. At the first antenatal visit, advise women to have oral health checks and treatment, if required. Good oral health protects a woman’s health and treatment can be safely provided during pregnancy.

Evidence supporting recommendation (see Section 10.5.5)

Cruz et al 2010; Khadar & Ta’ani 2005; Macones et al 2010; Michalowicz et al 2006; Michalowicz et al 2009; Newnham et al 2009;
Novak et al 2008; Offenbacher et al 2009; Plutzer & Spencer 2008; Srinivas et al 2009; Thomas et al 2008

Grading of evidence — Recommendation 29

Evidence base - A
Consistency - B
Clinical impact - C
Generalisablity - B
Applicability - A
Recommendation - B