Table Of Contents
Preconception
| Lifestyle | Safety & Risk | Medications | Vaccinations | Optimize pre-existing dz |
| smoking drugs sleep exercise stress | genetic dz carrier status, domestic violence, complications | Folic acid – all childbearing women take FA daily and women considering conception should start FA at least 1 month prior to attempting to conceive to reduce risk NTDs. – Low risk: 400-800 ug daily – Women with diabetes/epilepsy: 1 mg/day – Woman with child w/ previous NTD: 4 mg/day | Influenza HepB MMR | DM HTN Thyroid |
Screening Summary
| Trimester | Ultrasound | Tests/Labs | Genetic | Vaccines |
| 1st (1-12 weeks) | 10 Weeks: Confirm intrauterine pregnancy Assess gestational age Assess for aneuploidy Size/date discrepancies Vaginal bleeding Multiple gestations High-risk situations Follow up appointments: q4 wks: Until 28 wks [7 mos aka first 2 trimesters] q2 wks: Until 36 wks [9 mos aka third trimester] q1 wk: Until birth | Blood: CBC ABO blood type Rh status with antibody screen Hgb/Hct Rubella, Varicella titers, HIV, RPR Screen, HepB Urine: Urinalysis, urine culture, protein Pap screen for HPV Cervical swab for gonorrhea and Chlamydia Identify barriers to care and domestic abuse | Nuchal Translucency US (NT)<3mm PAPP-A hCG | |
| 2nd (13-28 weeks) | +abdominal circumference +cerebellar diameter +femur length +biparietal diameter of the skull – Anatomic malformations – Aneuploidies | Gestational diabetes (24-28 wks) Identify barriers to care and domestic abuse | Triple/Quad Screening: (15-20 wks) 1. alpha fetoprotein 2. beta hCG 3. Estradiol 4. Inhibin A +/-Amniocentesis | Downs: Increased HCG, inhibin A, decreased AFT and estriol Edwards: Decreased HCG, Inhibin A, AFT, and estriol Patua: none |
| 3rd (29-40 weeks) | fetal well being lie/orientation oligo/polyhydramnios | Rh Ab screen, Rh typing Anemia Identify barriers to care and domestic abuse |
Initial Prenatal Visit Lab Tests
- Blood group/Rh
- Antibody screen
- H/H (screening for anemia)
- Rubella antibody titer
- CDC – interval to 1 month for pregnancy after rubella vaccine
- Syphilis screen
- CDC and USPSTF – 3x if high risk
- Hepatitis B virus surface antigen
- Cervical cytology (if needed)
- STI
- GC/chlamydia
- Urine Culture (11-16 weeks EGA)
- Asymptomatic bacteriuria
- Sickle cell screen
- African American or Caribbean descent
- HIV screening
- Varicella screening
- +/- CF screening
- GDM screening
- Intake for Type 2 DM (if increased risk)
- Routine 24-28 weeks
1st Trimester (1 to 12 weeks)
Genetic Screening
| Advantages | |||
| Combined Screen | 1st + 2nd trimester | – Increased sensitivity – Decreased options | |
| Sequential Screen | 1st trimester then straight to invasive | – Increased invasiveness = increased fetal loss – Increased options | |
| Chorionic Villus Sampling | >10 weeks | Early detection, early termination |
Aneuploidy
| About | Diagnosis | Treatment | |
| Down’s 21 (Drinking age is 21) Edwards 18 (Election age is 18) Patau’s 13 (Pg-13) | Risk Increases with increased maternal age (35yrs) Prevalence = younger woman Pt: Asx screen Increased maternal age | Screening Tool (Non-invasive) Confirm Test (Invasive) | Termination |
Alloimmunization
| Path | Patient | Diagnosis | Treatment |
| Mom = Rh-Ag (-) had baby with Rh (+) Then if she has another baby that is Rh (+) then the mom will attack it with her Rh-Ab (+) and cause fetal anemia | Rh-Ag (-) mom | Rh-Ab (-) mom + Baby Rh-Ag (+) | Rh-D immune globulin at 18 weeks and within 72hrs of delivery |
2nd Trimester (13 to 28 weeks)
Transcranial Doppler
- When: 20wks
- Goal: Fetal Anemia (alloimmunization)
- Risk = None
- Extra: Highly sensitive, no diagnostic, no access
Maternal Anemia
| Path | Patient | Diagnosis | Treatment |
| Normal raio (drop of Hgb) = 10/30 (hub/hct) … if lower than 10 then probably iron deficiency | 24-28 weeks | Hgb <10, iron studies | Iron |
Percuaneous umbilical blood sampling (PUBS)
| Used For | Procedure | Advantages | Risks | Treatment |
| 20wks to 34wks allows access in setting of fetal anemia to transfuse | Transfuse |
Maternal Serum Alpha Fetoprotein (MSAFP)
| Used For | Elevated | Decreased | Advantages | Risks |
| Procedure when blood is drawn @ 15-20wks to detect NTD and abdominal wall defects | 1. Error in gestational age 2. Neural tube defects (anencephaly) 3. Abdominal wall defects (omphalocele, gastroschisis) 4. Multiple gestations Syndrome If positive: additional testing is required (CVS and Amniocentesis) | Down Syndrome Trisomy 21 | 80-85% NTD or abdominal defect & 90% anencephalies can be detected in early pregnancy. | High False-Positive rate >>Anxiety |
Multiple Marker Screening
| Triple Marker Test | Quad Marker Test | Interpretation | Advantages |
| AFP hCG Estriol levels | AFP hCG Estriol levels Inhibit A – inc. detection of Trisomy 21 to 80% | Increase levels of hCG and inhibin-A = levels 2x as high in Trisomy 21 Decrease levels of MSAFP and Estriol =suggest abnormality | 60-80% Trisomy 21 identified 85-90% open NTDs detected |
Amniocentesis
| Used For | Procedure | Advantages | Risks |
| To obtain amniotic fluid and fetal cells for: Genetic testing (Down Syndrome) Fetal Lung Maturity (FLM) Assessment of hemolytic disease in fetus Intrauterine infection (CMV, Rubella, Listeria) | Needle through abdominal wall—>uterine cavity—>obtain amniotic fluid | Completed between 14-20 wks. (genetic) > 20 weeks (FLM) > 99% accuracy | <1% fetal loss after 15 wks. (2-5% risk before 15 wks.) Placental or Fetal Trauma, Bleeding, Maternal Infection PTL/ROM |
Warning Signs
| Absent FHT | Dysuria, Urinary Urgency | Pelvic/Abdominal Pain | Prolonged Nausea & Vomiting | Severe Back Pain | Vaginal Bleeding/Spotting/Fluid |
| Fetal death or distress | UTI Vaginal Infection | PTL Appendicitis UTI Ovarian Torsion | Hyperemesis Gravidarium – More serious in the second trimester because it can lead to dehydration and other issues | PTL Pyelonephritis | Placenta Previa Friable cervix Vaginal Infection PTL |
