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First trimester__ Complete blood count (CBC) Blood type General antibody screen (indirect Coombs test) for HDN Rh D negative antenatal patients should receive RhoGam at 28 weeks to prevent Rh disease. Rapid plasma reagin (RPR) to screen for syphilis Rubella antibody screen Hepatitis B surface antigen Gonorrhea and Chlamydia culture PPD for tuberculosis Pap smear Urinalysis and culture HIV screen Genetic screening for downs syndrome (trisomy 21) and trisomy 18 the national standard in the United States is rapidly evolving away from the AFP-Quad screen for downs syndrome- done typically in the second trimester at 16–18 weeks. The newer integrated screen (formerly called F.A.S.T.E.R for First And Second Trimester Early Results) can be done at 10 plus weeks to 13 plus weeks with an ultrasound of the fetal neck (thick skin is bad) and two chemicals (analytes) Papp-a and bhcg (pregnancy hormone level itself). It gives an accurate risk profile very early. There is a second blood screen at 15 to 20 weeks which refines the risk more accurately. The cost is higher than an "AFP-quad" screen due to the ultrasound and second blood test but it is quoted to have a 93% pick up rate as opposed to 88% for the standard AFP/QS. This is an evolving standard of care in the United States. Second trimester__ MSAFP/quad. screen (four simultaneous blood tests) (maternal serum alpha-fetoprotein; inhibin; estriol; bhcg or free bhcg) - elevations, low numbers or odd patterns correlate with neural tube defect risk and increased risks of trisomy 18 or trisomy 21 Ultrasound either abdominal or trannsvaginal to assess cervix, placenta, fluid and baby Amniocentesis is the national standard (in what country) for women over 35 or who reach 35 by mid pregnancy or who are at increased risk by family history or prior birth history. Third trimester__ Hematocrit (if low, mother will receive iron supplementation) Group B Streptococcus screen – if positive, the woman will receive IV penicillin or ampicillin while in labor. If there is a penicillin allergy, alternative therapies include IV clindamycin or IV vancomycin. Glucose loading test (GLT) - screens for gestational diabetes; if > 140 mg/dL, a glucose tolerance test (GTT) is administered; a fasting glucose > 105 mg/dL suggests gestational diabetes. Most doctors do a sugar load in a drink form of 50 grams of glucose in cola, lime or orange and draw blood an hour later (plus or minus 5 minutes) ; the standard modified criteria have been lowered to 135 since the late 1980s Antenatal record__ On the first visit to her obstetrician or midwife, the pregnant woman is asked to carry out the antenatal record, which constitutes a medical history and physical examination. On subsequent visits, the gestational age (GA) is rechecked with each visit. Symphysis-fundal height (SFH; in cm) should equal gestational age after 20 weeks of gestation, and the fetal growth should be plotted on a curve during the antenatal visits. The fetus is palpated by the midwife or obstetrician using Leopold maneuver to determine the position of the baby. Blood pressure should also be monitored, and may be up to 140/90 in normal pregnancies. High blood pressure indicates hypertension and possibly pre-eclampsia, if severe swelling (edema) and spilled protein in the urine are also present. Fetal screening is also used to help assess the viability of the fetus, as well as congenital problems. Genetic counseling is often offered for families who may be at an increased risk to have a child with a genetic condition. Amniocentesis, which is usually performed between 15 and 20 weeks,[2] to check for Down syndrome, other chromosome abnormalities or other conditions in the fetus, is sometimes offered to women who are at increased risk due to factors such as older age, previous affected pregnancies or family history. Even earlier than amniocentesis is performed, the mother may undergo the triple test, nuchal screening, nasal bone, alpha-fetoprotein screening, Chorionic villus sampling, and also to check for disorders such as Down Syndrome. Amniocentesis is a prenatal genetic screening of the fetus, which involves inserting a needle through the mother's abdominal wall and uterine wall, to extract fetal DNA from the amniotic fluid. There is a risk of miscarriage and fetal injury with amniocentesis because it involves penetrating the uterus with the baby still in utero. Imaging__ A dating scan at 12 weeks. Imaging is another important way to monitor a pregnancy. The mother and fetus are also usually imaged in the first trimester of pregnancy. This is done to predict problems with the mother; confirm that a pregnancy is present inside the uterus; estimate the gestational age; determine the number of fetuses and placentae; evaluate for an ectopic pregnancy and first trimester bleeding; and assess for early signs of anomalies. X-rays and computerized tomography (CT) are not used, especially in the first trimester, due to the ionizing radiation, which has teratogenic effects on the fetus. No effects of magnetic resonance imaging (MRI) on the fetus have been demonstrated,[3] but this technique is too expensive for routine observation. Instead, obstetric ultrasonography is the imaging method of choice in the first trimester and throughout the pregnancy, because it emits no radiation, is portable, and allows for realtime imaging. Ultrasound imaging may be done at any time throughout the pregnancy, but usually happens at the 12th week (dating scan) and the 20th week (detailed scan). A normal gestation would reveal a gestational sac, yolk sac, and fetal pole. The gestational age can be assessed by evaluating the mean gestational sac diameter (MGD) before week 6, and the crown-rump length after week 6. Multiple gestation is evaluated by the number of placentae and amniotic sacs present. Fetal assessments__ Obstetric ultrasonography is routinely used for dating the gestational age of a pregnancy from the size of the fetus, the most accurate dating being in first trimester before the growth of the fetus has been significantly influenced by other factors. Ultrasound is also used for detecting congenital anomalies (or other fetal anomalies) and determining the biophysical profiles (BPP), which are generally easier to detect in the second trimester when the fetal structures are larger and more developed. Specialised ultrasound equipment can also evaluate the blood flow velocity in the umbilical cord, looking to detect a decrease/absence/reversal or diastolic blood flow in the umbilical artery. Other tools used for assessment include: Fetal karyotype can be used for the screening of genetic diseases. This can be obtained via amniocentesis or chorionic villus sampling (CVS) Fetal hematocrit for the assessment of fetal anemia, Rh isoimmunization, or hydrops can be determined by percutaneous umbilical blood sampling (PUBS) which is done by placing a needle through the abdomen into the uterus and taking a portion of the umbilical cord. Fetal lung maturity is associated with how much surfactant the fetus is producing. Reduced production of surfactant indicates decreased lung maturity and is a high risk factor for infant respiratory distress syndrome. Typically a lecithin:sphingomyelin ratio greater than 1.5 is associated with increased lung maturity. Nonstress test (NST) for fetal heart rate Oxytocin challenge test Complications and emergencies__ This section is in a list format that may be better presented using prose. You can help by converting this section to prose, if appropriate. Editing help is available. (May 2010) Main article: Complications of Pregnancy The main emergencies include: Ectopic pregnancy is when an embryo implants in the Fallopian tube or (rarely) on the ovary or inside the peritoneal cavity. This may cause massive internal bleeding. Pre-eclampsia is a disease which is defined by a combination of signs and symptoms that are related to maternal hypertension. The cause is unknown, and markers are being sought to predict its development from the earliest stages of pregnancy. Some unknown factors cause vascular damage in the endothelium, causing hypertension. If severe, it progresses to eclampsia, where convulsions occur, which can be fatal. Preeclamptic patients with the HELLP syndrome show liver failure and Disseminated intravascular coagulation (DIC). Placental abruption where the patient can bleed to death if not managed appropriately. Fetal distress where the fetus is getting compromised in the uterine environment. Shoulder dystocia where one of the fetus' shoulders becomes stuck during vaginal birth, especially in macrosomic babies of diabetic mothers. Uterine rupture can occur during obstructed labor and endangered fetal and maternal life. Prolapsed cord refers to the prolapse of the fetal cord during labor with the risk of fetal suffocation. Obstetrical hemorrhage may be due to a number of factors such as placenta previa, uterine rupture or tears, uterine atony, retained placenta or placental fragments, or bleeding disorders. Puerperal sepsis is a progressed infection of the uterus during or after labor. Intercurrent diseases__ Main article: Intercurrent disease in pregnancy In addition to complications of pregnancy that can arise, a pregnant woman may have intercurrent diseases, that is, other diseases or conditions (not directly caused by the pregnancy) that may become worse or be a potential risk to the pregnancy. Diabetes mellitus and pregnancy deals with the interactions of diabetes mellitus (not restricted to gestational diabetes) and pregnancy. Risks for the child include miscarriage, growth restriction, growth acceleration, fetal obesity (macrosomia), polyhydramnios and birth defects. Systemic lupus erythematosus and pregnancy confers an increased rate of fetal death in utero and spontaneous abortion (miscarriage), as well as of neonatal lupus. Thyroid disease in pregnancy can, if uncorrected, cause adverse effects on fetal and maternal well-being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and delivery to affect neurointellectual development in the early life of the child. Demand for thyroid hormones is increased during pregnancy which may cause a previously unnoticed thyroid disorder to worsen. Hypercoagulability in pregnancy is the propensity of pregnant women to develop thrombosis (blood clots). Pregnancy itself is a factor of hypercoagulability (pregnancy-induced hypercoagulability), as a physiologically adaptive mechanism to prevent post partum bleeding.[4] However, when combined with an additional underlying hypercoagulable states, the risk of thrombosis or embolism may become substantial.[4] |
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