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High-risk pregnancies (also known as high-risk obstetrics) tend to come with more challenges and dangers than normal pregnancies. You will need to visit your OB-GYN more often and undergo more testing than during a typical pregnancy to check up on your health and the health of your baby.
BICORNUATE UTERUS AND PREGNANCY
The shape of the uterus is a pear. When you’re not pregnant, it measures about 3 inches long, 2 inches wide, and 1 inch deep.
During pregnancy, the baby grows in the upper portion of the uterus, called the fundus. The lower part of the uterus dives little ways into the vagina and creates an opening called the cervix. This is the opening that dilates to let the baby pass through during delivery.
Some women are born with congenital uterine anomalies. A bicornuate uterus is a heart-shaped uterine abnormality. The fundus has a sharp indentation at the top, with two “horns” that connect to the Fallopian tubes.
This heart-shaped uterus abnormality is not very common. About 1 in 200 women are estimated to have a bicornuate uterus. Most of these women don’t realize they have the condition until they get pregnant.
But this condition can result in a significant impact on your ability to conceive as well as carry a successful pregnancy. Some women have an abnormally developed uterus from birth (congenital) while others may develop a uterine problem from surgery or past infection.
There are many different fertility problems that involve the uterus contributing to infertility and recurrent miscarriage including Uterine fibroids, Congenital abnormalities, Asherman’s syndrome, Adenomyosis, and DES.
Incomplete fusion of the Mullerian or paramesonephric ducts results in the most common types of uterine malformation: such as the septate uterus, unicornuate uterus, and bicornuate uterus. These uterine malformations are rare but known to be associated with infertility, pregnancy loss, intrauterine growth restriction, preterm deliveries, preterm prelabour rupture of membranes, breech presentation, and increased rate of cesarean section. However, normal reproductive performance has been seen in association with them.
BLEEDING DURING PREGNANCY
It’s not uncommon for pregnant women to experience spotting or light bleeding during early pregnancy. In fact, approximately 20% of pregnant women experience light bleeding or spotting during the first trimester of pregnancy. Most women go on to have uncomplicated pregnancies and ultimately deliver a healthy baby.
If this happens to you, don’t be alarmed, especially if you notice it after sexual intercourse. But, sometimes vaginal bleeding during pregnancy is an indicator of a serious issue. Common problems that may cause light bleeding later in pregnancy include inflammation of or growths on the cervix.
But heavy bleeding is a more serious sign and should not be ignored. Heavy bleeding may be caused by a problem with the placenta.
If you’re concerned about vaginal bleeding during pregnancy, even if it is just the first trimester, please do not hesitate to call us. We can perform a pelvic exam and ultrasound, and if there is any cause for concern, we can order other diagnostic tests. Be prepared for your health care professional to ask you for a complete medical history, including how much bleeding you’ve had, and if you’ve experienced any pain.
BLOOD CLOTTING DISORDERS AND PREGNANCY
Pregnancy increases women’s risk of blood clotting disorders. For women with a family history of clotting disorders, the risk is even greater.
They are also considered to be at high risk for pregnancy complications because they and the women in her family may have had a history of preeclampsia, pregnancy loss, blood clots in a leg or lung, a low-birth-weight baby, or placental abruption, where the placenta separates from the wall of the uterus before delivery.
Blood clots block arteries and blood vessels, diminishing or altogether preventing blood flow to essential organs. In pregnant women, this can include the placenta. When blood flow is interrupted in the placenta, the baby is starved of the nutrients and oxygen it needs for healthy development.
Risks of Clotting Disorders
Thrombophilia is a condition in which blood has an increased tendency to clot. The disease threatens the mother’s health, but it will cause other pregnancy complications, including:
- Intrauterine Growth Restriction (IUGR).
- Severe Preeclampsia.
- Miscarriage after 10 weeks.
- Placental abruption (the placenta separates from the uterine lining too soon).
It’s not inherently dangerous to have a large newborn, but the chances of complications are higher when carrying and delivering a large baby. Fetal macrosomia also puts the baby at an increased risk of health problems after birth. These risk factors increase significantly when the newborn birth weight is more than 9lbs, 15oz.
Fetal macrosomia may complicate natural delivery and could put the macrosomic baby at risk of injury during birth, as well as the pregnant women giving delivery to a macrosomic infant.
The American College of Obstetricians and Gynecologists (ACOG) defines fetal macrosomia as a newborn is considered larger than average if it weighs more than 8lbs, 13oz at birth, no matter how long its gestational age. Roughly 9% of new infants are macrosomic. But these thresholds are not useful for identifying the preterm macrosomic fetus since they are not based upon population statistics, where normal weight is typically defined as between the 10th and 90th percentile for gestational age.
Signs and Symptoms of Fetal Macrosomia
Unfortunately, the ultrasound techniques do not have high reliability in the detection and prediction of macrosomia and the probability of a correct diagnosis of macrosomia by ultrasound tests is not very high. Often manifests with truncal obesity and therefore the abdominal circumference may be one of the first parameters to increase.
- Fundal height. At each prenatal visit, your OB-GYN will measure your fundal height. This is the length between the pubic bone and the very top of your uterus. An abnormally large fundal height could be a sign that the baby may be larger than normal and maybe macrosomic.
- Amniotic Fluid. The amount of amniotic fluid can be measured to estimate the size of the fetus. If your doctor finds excessive amniotic fluid during a prenatal visit, this may be an indication of fetal macrosomia. Excessive amniotic fluid defined as greater than or equal to the 60th percentile for gestational age has recently been associated with macrosomia.
Causes of Fetal Macrosomia
There are many cases when the cause of fetal macrosomia is unknown. However, some conditions do seem to affect the incidence rate of macrosomia, and some of these maternal risk factors are more or less under your control:
- Maternal diabetes. If the mother has diabetes or develops diabetes while pregnant (gestational diabetes), she is more likely to give birth to a large baby.
- Maternal obesity. High pre-pregnancy body mass index (BMI)
- Gaining excessive weight during pregnancy.
- Maternal age. Women over 35 are more at risk for fetal macrosomia.
- History of macrosomia. If you have given birth to a large baby in the past, or if you yourself weighed more than 8lbs, 13oz at birth, then you are more likely to carry a large baby.
- Previous pregnancies. And if you’ve had a macrosomic baby before, you’re more likely to deliver another one the next time around, since the risk of macrosomia increases with each pregnancy.
- The baby is a boy. Male infants tend to weigh more than female infants.
- Overdue pregnancy. If you’re more than two weeks past your due date, the odds of high birth weight are greater.
Fetal malpositions are abnormal positions of the vertex presentation of the fetal head (with the occiput as the reference point) relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex. As the baby reaches the final stages of pregnancy, it moves into position for delivery. If the mother is lying on her back, the most common and safest fetal malpresentation for the baby is:
- Facing downward
- Coming out headfirst
- Tucking its chin into its chest
- Folding its arms across the chest
- Angling its face and body to the right or left of the mother’s spine
There are many variations on this position, which are called malpresentation or abnormal presentations. Your doctor can sometimes correct the baby’s presentation, but in some cases, it’s safest to deliver via C-section. It is one of the most common reasons for cesarean deliveries.
If the presentation is known beforehand, then the delivery of the baby should be scheduled in a healthcare facility where surgical intervention, if indicated, can be performed. After 37 weeks of gestation when the woman is in early labor, the external cephalic version can be attempted if vaginal delivery is deemed possible, if it is a single gestation, if membranes are intact, if the fetus has no growth retardation or anomalies, and there is no vaginal bleeding or history of a previous cesarean section.
Vaginal delivery can proceed if the external cephalic version is successful. If it is unsuccessful, then either a vaginal breech delivery should be attempted, or a cesarean delivery scheduled immediately.
GESTATIONAL DIABETES: RISKS & TREATMENTS
RISKS & TREATMENTS
During pregnancy, some women develop high blood sugar levels. Gestational diabetes is a type of diabetes that occurs only during pregnancy. Gestational diabetes can cause health problems in both mother and baby. This condition is known as gestational diabetes mellitus or gestational diabetes. Gestational diabetes typically develops between the 24th and 28th weeks of pregnancy. Gestational diabetes often occurs in women who have no prior family history of diabetes.
Like other forms of diabetes, gestational diabetes impairs your body’s ability to absorb glucose and leads to high blood sugar levels. When you get pregnant, the placenta produces a number of hormones to help regulate the baby’s nourishment. Oddly enough, nearly all of these hormones impair the ability of insulin to do its job. This raises your blood sugar levels, and in fact, most women will see elevated blood sugar levels after a meal throughout their pregnancy. This is perfectly normal.
However, as the pregnancy reaches the later stages, it can become difficult for the woman’s blood sugar to level out. When her body detects a heightened level of glucose in the blood, it produces more insulin to try to get it under control. She could then develop insulin resistance, leading to gestational diabetes. Gestational diabetes may also increase the mother’s risk of high blood pressure and preeclampsia.
Gestational diabetes can be dangerous, and it requires careful monitoring by an Ob/Gyn. Having the disease increases the baby’s risk of:
- Growing very large inside the mother, also known as macrosomia. May require a c-section for delivery.
- High birth weight
- Pre-term labor
- Low glucose levels
Keep in mind that you can manage these risks with proper prenatal care and careful glucose monitoring.
Fortunately, most cases of gestational diabetes disappear after pregnancy. However, these women and their babies will always have an increased risk of diabetes in the future and must watch out for signs of the disease. Women who had diabetes prior to their pregnancy, whether diagnosed or not, will have the condition for life.
Causes of Gestational Diabetes
While there are often no symptoms, some may experience:
- Excessive thirst
- Frequent urination
HYPERTENSION IN PREGNANCY
When the heart pumps blood through the body, the measure of the pressure against the vessels’ walls is called blood pressure. High blood pressure while pregnant (also known as Hypertension in Pregnancy), carries serious health risks. Severe hypertension can threaten you and you’re baby’s health. Some women have high blood pressure before they get pregnant. Others have high blood pressure for the first time during pregnancy.
Hypertension during pregnancy can lead to a very dangerous complication called preeclampsia. Severe forms of preeclampsia may develop alongside even more dangerous conditions, such as eclampsia (seizures during preeclampsia) and HELLP syndrome.
All pregnant women need to understand the warning signs of these conditions, which can be fatal if left untreated. Hypertensive disorders of pregnancy are common and remain a significant cause of maternal and fetal morbidity.
INTRAUTERINE GROWTH RESTRICTION (IUGR)
Intrauterine growth restriction (IUGR) occurs when the baby grows at a slower pace than normally expected, and is unable to reach its full growth potential while in utero. After the 20th week of pregnancy, the measure in centimeters usually corresponds with the number of weeks of pregnancy. A lower than expected measurement may indicate the baby is not growing as it should. Other terms used for IUGR is fetal growth restriction and intrauterine growth retardation.
It’s difficult to say exactly how much a fetus weighs when it’s inside the mother. Babies with IUGR may be born small and/or undernourished. Intrauterine growth restriction, which is defined as less than 10th percentile of predicted fetal weight for gestational age, may result in significant fetal morbidity, future health problems, and mortality if not properly diagnosed.
Risks of IUGR
IUGR can put the baby at risk for complications during pregnancy, birth, and even after delivery. Some of these risks include:
- Low birth weight
- Decreased oxygen
- Low blood sugar (hypoglycemia)
- Difficulty enduring the stresses of natural vaginal birth
- High red blood cell count
- Fluctuating body temperature
- Susceptibility to infection
- Meconium aspiration. These are breathing problems caused by the newborn inhaling its first stool, which can be prematurely expelled during stressful labor, instead of after birth.
- Low Apgar scores. Apgar tests evaluate a newborn’s health and assess its need for specialized care.
Multiple gestations (or multiple pregnancies) is when a woman is pregnant with more than one fetus. She may be expecting twins, triplets, or more. Most women learn they’re pregnant with multiples during the first trimester. The signs of multiple gestations are usually more severe forms of the symptoms of pregnancy.
In humans, the average length of pregnancy (two weeks fewer than gestation) is 38 weeks with a single fetus. This average decreases for each additional fetus: to thirty-six weeks for twin births, thirty-two weeks for triplets, and thirty weeks for quadruplets. With the decreasing gestation time possibly causing preterm birth, the risks from immaturity at birth and subsequent viability increase with the size of the sibling group. Only as of the twentieth century have more than four all survived infancy.
Recent history has also seen increasing numbers of multiple births. In the United States, it has been estimated a higher number of twin births, triplets, and higher-order births have resulted from conception by assisted reproductive technology.
There are Two Types of Multiple Pregnancies
When more than one fetus originates from the same egg, we call them identical. A single egg is fertilized by a single sperm, and then the egg spontaneously splits into two genetically identical embryos. It’s not clear why this happens, and there’s no correlation between the likelihood of having identical babies and your race, age, or family history.
Identical twin gestation babies will all be the same sex and will have the same blood type. Although identical twins usually look very much the same (same eye and hair color, body type, etc), they don’t always look 100% identical. Many other factors play a role in shaping your child’s appearance. They’ll even have their own unique fingerprints!
When two or more eggs are fertilized by more than one sperm, the resulting babies are fraternal. Unlike identical pregnancies, fraternal pregnancies do run in families. If any relatives on your mother’s side had fraternal twins, the chances that you will have them too are greater. Fraternal pregnancies are also more common in women over 35, women of African descent, and women who have just quit taking birth control pills.
Although fraternal babies are very similar to each other due to having the same parentage, they are genetically different, and will likely resemble each other as much as ordinary brothers and sisters do. Fraternal babies can be both sexes and may have different blood types.
OLIGOHYDRAMNIOS AND POLYHYDRAMNIOS
Occasionally, a pregnancy can produce either too little or too much amniotic fluid, which is the fluid that surrounds the baby. What results is a set of possible risks or complications known as oligohydramnios (OH-lee-go-hy-DRAM-nee-os) and polyhydramnios (pol-ee-hy-DRAM-nee-os).
Amniotic fluid cushions the baby from outside stress and gives the baby enough room to move and grow inside the womb. It also keeps some space between the baby, the umbilical cord, and the uterine wall, so that the cord doesn’t become compressed.
Because the amniotic fluid typically reflects the amount of fetus urine production, it’s used as a measure of the baby’s health and development. Amniotic fluid volume cushions the fetus from physical trauma permits fetal lung growth and provides a barrier against infection. Normal amniotic fluid volume varies. If the amount of fluid is low, it may be an indication that:
- Your water is breaking
- The baby has intrauterine growth restriction (IUGR) Placental insufficiency and fetal growth restriction
- The baby is having kidney or urinary tract problems
- The baby has a rare genetic disorder
- The placenta is separating from the uterine wall prematurely (placental abruption)
- The mother has chronic high blood pressure or is using certain medications, such as ACE inhibitors
An inadequate volume of amniotic fluid, oligohydramnios, results in poor development of the lung tissue and can lead to fetal death. In the latter two-thirds of pregnancy, any condition that interferes with fetal urine production can lead to oligohydramnios. Renal agenesis, cystic kidneys, and bladder outlet obstructions are common.
Too little fluid for long periods may cause abnormal or incomplete development of the lungs called pulmonary hypoplasia.
Polyhydramnios occurs when there is an excessive accumulation of amniotic fluid. Too much amniotic fluid can cause the mother’s uterus to become overdistended and may lead to preterm labor or premature rupture of membranes. Polyhydramnios has many different causes, and the recommended treatments can vary.
Most cases of polyhydramnios are mild. Amniotic fluid volume increase during pregnancy, the actual volume that constitutes polyhydramnios is dependent on the gestational age of the fetus. Amniotic fluid may have gradually built up during the later stages of pregnancy. Normally, this won’t cause any problems and will go away on its own.
However, severe polyhydramnios may cause outward symptoms, such as shortness of breath, swelling in the feet, ankles, and vulva, and decreased urine production.
Fetuses with polyhydramnios are at risk for a number of other problems including cord prolapse, placental abruption, premature birth, and perinatal death.
PREGNANCY AND AUTOIMMUNE DISORDERS
Autoimmune disorders such as autoimmune thyroid disease (Hashimoto and Graves’ disease), celiac disease, type 1 diabetes, inflammatory bowel disease, and psoriasis have been on the rise in the last 20 years. Autoimmune disorders are conditions in which an ongoing, self-directed immune response results in clinical manifestations.
In the past, women with autoimmune diseases were frequently counseled against conceiving. Today, more and more women with a range of autoimmune conditions are enjoying healthy pregnancies. However, they are still considered high-risk pregnancies.
Autoimmune disorders are 5 times more common among women, and incidence tends to peak during reproductive years. Thus, these disorders commonly occur in pregnant women.
A healthy, normally-functioning immune system is designed to fight off harmful invaders, like bacteria or viruses. An autoimmune disorder or autoimmune disease is a condition in which the body’s immune system attacks your own healthy cells. There are many ways that pregnancy and autoimmune disorders can interact. In some cases, pregnancy may have a profound effect on the symptoms of autoimmune diseases, such as in the case of Rheumatoid arthritis and multiple sclerosis.
- Pregnancy may trigger an autoimmune disorder.
- An existing autoimmune disorder can interfere with pregnancy, causing harm to the fetus.
- The antibodies that the mother produces can enter the fetus’s system, affecting its growth.
Antibodies and antigens join to form a floating immune complex, which circulates in maternal blood and can clog the filter of the placenta, causing it to become partially blocked. If the amount and number of nutrients crossing the fetal membrane decreases, the baby will be smaller. These moms have to be watched—especially in the late second and entire third trimester—for early placental dysfunction. Trouble starts when a woman develops placental vasculitis, an inflammation of the capillaries. WBCs come in and try to clean up the problem, but they heal by scarring. This often leads to cell death within the placenta and decreases placental function. Women with vasculitis are at increased risk of preterm delivery and small-for-gestational-age infants.
It is recommended that women with autoimmune diseases achieve remission, meaning their symptoms disappear or substantially improve, for at least six months before pregnancy. Women whose autoimmune conditions are in remission typically have a reduced risk of pregnancy complications and symptom flare-ups.
Your health care provider can adjust your medications and monitor your symptoms to help you achieve this goal.
PLACENTA ABNORMALITIES (PLACENTA PREVIA)
Normal development of the placenta during pregnancy is essential for an uneventful delivery. The placenta and its health are vital to the health of a woman’s pregnancy and fetal development.
The placenta is the organ that develops during pregnancy to nourish the baby. It grows inside the uterine wall, connecting to the baby through the umbilical cord. The fetal side of the placenta is called the chorionic plate, and the maternal side is called the basal plate. Throughout your pregnancy, the placenta is responsible for getting nutrients and oxygen into your baby’s bloodstream, as well as removing its waste products. Placental insufficiencies, intrauterine growth restrictions, and other placental conditions can cause issues for both mother and infant.
In rare cases, a pregnancy might take on some additional risks, due to Placenta Abnormalities.
Risk Factors for Placenta Abnormalities Include:
- High blood pressure
- Multiple gestation pregnancy
- History of uterine surgery
- History of placental problems
- Maternal drug use
- Trauma to the abdominal
- High maternal age
- Maternal blood-clotting disorders
- History of smoking
PRETERM LABOR (PREMATURE LABOR)
Preterm labor (also called premature labor) is defined as labor that begins earlier than 37 weeks into the pregnancy. If the baby is born between 20 and 37 weeks, it is considered a preterm birth. It’s when your body starts getting ready for birth too early in your pregnancy. Labor is premature if it starts more than three weeks before your due date.
When a pregnant woman enters preterm labor, the uterine contractions cause the cervix to thin out, and/or dilate early.
Preterm birth is a pregnancy complication that can result in serious consequences. The baby may not have had enough time in the womb to reach its full growth potential. Essential organs and systems may not be ready to sustain the baby outside its mother without medical intervention.
Some premature babies have serious health problems, like cerebral palsy and other long-term physical and learning disabilities. Risks of preterm labor include delivering a preterm baby. This can pose a number of health concerns for your baby, such as low birth weight, breathing difficulties affecting the baby’s lungs, underdeveloped organs, and vision problems.
Many factors can contribute to preterm labor. Although the exact cause of preterm labor is unknown in many cases, one major cause is the premature rupture of membranes (breaking of the amniotic sac).
Risk Factors for Preterm Birth
Some pregnancies have a higher risk of premature birth than others. Factors that increase the risk of preterm labor include:
- Being underweight during the pregnancy
- Smoking, drug, or alcohol abuse during pregnancy
- Previous preterm birth
- When it’s been less than two years since the last pregnancy
- Having a short cervix
- Prior surgery on the cervix or uterus
- Multiple pregnancies
- Vaginal bleeding
- No prenatal care
- Have health conditions, such as diabetes or high blood pressure
(LOW PLATELET COUNT) IN PREGNANCY
(LOW PLATELET COUNT)
Thrombocytopenia – or low platelet count – is not uncommon, affecting about 8% of pregnancies. The majority of these cases are mild and don’t pose any problems to the woman or her baby. Thrombocytopenia has many causes. One of the most common causes of low platelets is a condition called immune thrombocytopenia (ITP). The two main causes of thrombocytopenia are a decrease in the production of platelets in the bone marrow and an increase in the destruction of the platelets.
Moreover, most pregnant women with ITP may have a history of thrombocytopenia prior to pregnancy or may present with other immune-mediated diseases.
Mild gestational thrombocytopenia is relatively frequent during normal pregnancy and has generally no consequences for either the mother or the fetus. Although with no real threat in the majority of patients, thrombocytopenia may result from a range of pathologic conditions requiring closer monitoring and possible therapy.
Two clinical scenarios are particularly relevant for their prevalence and the issues relating to their management. The first is the presence of isolated thrombocytopenia and the differential diagnosis between primary immune thrombocytopenia and gestational thrombocytopenia. The second is thrombocytopenia associated with preeclampsia and its look-alikes and their distinction from thrombotic thrombocytopenic purpura and the hemolytic uremic syndrome.
When diagnosed in pregnancy, the condition is called gestational thrombocytopenia. However, some women may have chronic cases of immune thrombocytopenia, that went undiscovered until their routine prenatal blood tests. Preeclampsia occurs in 3 to 4% of pregnancies and accounts for 5 to 21% of cases of maternal thrombocytopenia.
UTERINE FIBROIDS AND PREGNANCY
Uterine fibroids are benign growths of the uterus. Most uterine fibroids are completely harmless and have no outward symptoms. They can be as small as a pea. And some can be large fibroids, like the size of a grapefruit. They can grow outside the uterine wall, inside the uterine cavity, or within the uterine wall. Many women have multiple fibroids of different sizes. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids project to the outside of the uterus. Some submucosal or subserosal fibroids are pedunculated — they hang from a stalk inside or outside the uterus.
Uterine fibroids are pretty common – around one-fifth of women will develop uterine fibroids at some point in their life. Research is still out on their specific causes, but they may be related to hormones and genetics. While we don’t have any methods of preventing fibroids, the possibility of developing them should not be worrisome.
70-80% of women will have uterine fibroids by the age of 50 and between 20-50% of women of childbearing age have fibroids.
COMPREHENSIVE PreNATAL SERVICEs PROGRAM
CPSP is a statewide program that provides enhanced reimbursement for a wide range of services to Medi-Cal eligible pregnant and postpartum women. The CPSP model was founded on the belief that pregnancy and birth outcomes improve when routine obstetric care (prenatal, delivery, and postpartum care) is integrated with specific nutrition, health education, and psychosocial services. CPSP was developed from OB Access, a successful perinatal demonstration project for low-income women that was conducted from 1979 to 1982 in 13 California counties.
Comprehensive services were shown to reduce the low birth weight rate by one-third and to save approximately $2 in short-term NICU costs for every $1 spent. Because of these positive results, a statewide program to deliver these services was legislated in 1984.
Comprehensive prenatal services program
- To decrease the incidence of low birthweight in infants
- To improve the outcome of every pregnancy
- To give every baby a healthy start in life
- To lower health care costs by preventing catastrophic and chronic illness in infants and children
Assessments, reassessments, treatment, interventions in:
- Obstetrics and individual case coordination
- Health education
- Psychosocial services
- Perinatal and parenting education and Vitamin/mineral supplements
- Referrals to WIC, genetic screening, dental care, family planning and pediatric care.
Any physician, certified nurse midwife, nurse practitioner, hospital, community clinic, or medical group who provides prenatal care, has a valid Medi-Cal provider number, and is in good standing with state licensing and regulatory agencies. Provider participation requires a formal application process and certification by the State Department of Health Services. Once finalized at the local CPSP office, the application is forwarded to the California Dept. of Public Health for final approval. Only state-approved providers can bill for CPSP services. . All Medi-Cal managed health plans are required to ensure that their pregnant enrollees have access to the CPSP services. Therefore, all pregnant women eligible for Medi-Cal are eligible to receive CPSP services.
The local Perinatal Services Coordinator (PSC) provides guidance to assist providers with the certification process and provides technical assistance with program implementation to certified providers.
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