Testing in Pregnancy

1. Nizar F. Olabi, DO Provena Mercy Medical Center Testing in Pregnancy

2. General testing Testing throughout pregnancy

3. General Testing: Blood Testing • Blood test: a sample of blood is taken from a vein in your arm and sent to a lab for analysis. • Risk: no risks to the mother or developing baby • What can be found? • Many different diagnosis can be made by a simple blood test. • These results will better equip your physician to care for you and your un-born child throughout the pregnancy. • These results may also help to predict potential complications with you or your baby at birth.

4. What are we looking for? • Blood type • Rh Factor: this may show a need for an additional medication to keep your blood and the baby’s blood from interacting during the birthing process • Glucose level: can indicate diabetes • Iron level: susceptibility to anemia • Hemoglobin Level: anemia if counts are too low • Sexually Transmitted Diseases: syphilis, hepatitis B or HIV which may require treatment to keep you and the baby safe • Rubella (German Measles): antibodies showing immunity • Toxoplasmosis: this is harmless to you but may cross the placenta and harm the baby

5. General Testing: Urine • Urine sampling: done by obtaining a small sample of urine (midstream) into a sterile cup. • This will occur many times throughout the pregnancy. • Risk: no risk to mom or baby • Simple testing will determine presence of: • Sugar: too much may indicate need for further testing for gestational diabetes • Ketones: indicate nutrition and hydration level • Protein: indicate a potential problem with the kidneys (infection) or a need for pre-eclampsia workup • Bacteria: indicates a possible urinary tract infection requiring treatment

6. General Testing: Vaginal exams • Vaginal exams • Pelvic exam: a manual exam (the doctor uses his fingers) to determine • Your gestational age by the shape of the pelvis, uterus, pelvic bones • Presence of any masses, ovarian cysts or fibroids • Cervical exam: a manual exam to check if your cervix is open/closed • PAP smear: a speculum exam where the doctor uses a swab to remove a few cervical cells to test for abnormal cells (pre-cancerous) • Vaginal culture: a speculum exam where the doctor swabs the cervix to determine the presence of chlamydia and gonorrhea. • Risk: low/no risk to mom and baby

7. General Testing: Paternity • Pre-natal (before birth) • Pre-natal testing does present an increased risk to mother and fetus when compared to post-natal testing. • Amniocentesis: a DNA test is done on the amniotic fluid surrounding your unborn baby. • Chorionic Villus Sampling: a DNA test is done on a sample of tissue attached to the uterus is taken via the vagina and cervix. • This is done to determine the father of the child. • May cost $400-$2000 depending on the lab performing and type of testing done. • Post-natal (after birth) • Blood testing • Cheek swab • Umbilical cord testing

8. General Testing: Ultrasound • Transvaginal: probe is inserted into the vagina to obtain images EARLY in pregnancy. • Standard Ultrasound: probe place on the abdomen and generates a 2D image of the baby. • Advanced Ultrasound: probe still placed on the abdomen but is targeting a suspected problem using more sophisticated equipment. • Doppler Ultrasound: detects blood flow and movement using ultrasound waves. • 3D-ultrasound: generate 3D images of the baby in the uterus. • 4D or dynamic 3D ultrasound: looks at the face of the baby and detects movements prior to delivery. • Fetal echocardiography: examines the baby’s heart anatomy and function in the uterus.

9. General Testing: Ultrasound • First Trimester: • Confirming viability • Confirming heartbeat • Measuring gestational age • Confirming molar or ectopic pregnancy • Assessing for abnormal gestation • Second Trimester: • Fetal malformation • Wks 13-14 potential Down Syndrome characteristics • Wks 18-20 congenital anomalies • Structural abnormalities • Multiples in pregnancy • Verification of dates and growth • Confirming intrauterine death • Identifying excessive or reduced levels of amniotic fluid • Evaluation of fetal well-being

10. General Testing: Ultrasound • Third Trimester: • Identifying placental location • Confirming intrauterine death • Fetal presentation • Fetal movements • Identification of uterine and pelvic abnormalities in the mother. • Ultrasound may be encouraged by your doctor if there is medical concern for mom or baby. • Questions?? • Heartbeat: early in the pregnancy (6-7 wks) it is OK to not find the heartbeat initially • Gender of the baby may be determined at 18-20 wks. • Ultrasounds are done according to patient needs, baby needs, and physician discretion.

11. First Trimester Screening Procedures for the First 3 months of Pregnancy

12. First Trimester • “First Trimester Screen” • Determines risk for potential chromosomal abnormalities • Done according to MD recommendation • Chorionic Villus Sampling • Determines chromosomal abnormalities. • Done when mom and dad medical history supports need.

13. First Trimester • “First Trimester Screen” • Performed at 11-13 wks at the recommendation of your doctor • Simple blood test: hCG and PAPP-A (pregnancy hormones) • Ultrasound: measure nuchal translucency • Combines the two results • Assesses for potential risk for: • Down’s Syndrome Trisomy-21 and Trisomy-18 • Cardiac disorders • Abnormal results may suggest need for additional testing

14. First Trimester • Chorionic Villus Sampling • Used to identify chromosomal abnormalities or other inherited disorders • Only indicated if you or your partner has a medical history that reveals a potential risk. • Abnormalities detected: • Down syndrome • Cystic fibrosis • Also can be used for paternity testing • Risks: invasive procedure, risk to mom and fetus. • 1 out of every 100 tested experience miscarriage. • Side effects: • Infection • Spotting • Cramping • Pain at puncture site (abdomen or cervix)

15. Second Trimester Screening Procedures for the Next 3 months of Pregnancy

16. Second Trimester • These may be recommended by your physician during your second trimester or simply offered as a screening method • Quad Screen • Same as triple screen with addition of Inhibin-A (more sensitive to Down Syndrome) • Triple Screen Test: multiple marker screen • Amniocentesis • Maternal Serum Alpha-Fetoprotein Screen • Cordocentesis (percutanteous umbilical blood sampling)

17. Second Trimester • Quad screen is recommended for women who: • Have family history of birth defects • Are 35 yrs or older • Used harmful medications or drugs during pregnancy • Have diabetes and use insulin • Had a viral infection during pregnancy • Have been exposed to high levels of radiation • Blood testing: • Quad screen: • Alpha-fetoprotein level • hCG level • Estriol level • Inhibin-A level • Based on the levels found, combined with maternal age and race the lab determines a probability of chromosomal anomaly like Down’s syndrome or cystic fibrosis.

18. Second Trimester • Amniocentesis • Follow up to abnormal Triple or Quad Screen • Performed usually between 14-20 wks • Ultrasound guided • Needle aspiration of fluid from the amniotic sac through the stomach • Detects: • Chromosomal abnormalities • Neural tube deficits • Genetic disorders • Does not measure severity of deficits or abnormalities

19. Second Trimester: (uncommon) • Cordocentesis • Umbilical cord sampling • Ultrasound guided • Needle inserted into the umbilical cord where it meets the placenta for a blood sample • Typically done when information cannot be obtained through amnio, CVS or ultrasound • Assessing for: • Malformations of the fetus • Fetal infection • Fetal platelet count • Fetal anemia • Isoimmunisation: mom develops antibodies against baby’s blood cells (rH incompatibility) • Does NOT test for neural tube deficits • Highly accurate • Risks to mom and baby • Miscarriage (1-2 out of 100) • Blood loss from puncture site • Infection • Drop in FETAL heart rate • Premature rupture of membranes

20. Third Trimester Screening Procedures for the final months of Pregnancy

21. Third Trimester • Testing in this trimester may aid the physician in planning your delivery and any potential complications • Testing includes: • Biophysical Profile • Glucose Tolerance Test • 1 hour • 3 hour • Fetal Non-Stress Test (NST) • Group B Strep

22. Third Trimester • Fetal Non-Stress Test (NST) • Two belts are placed on mom’s abdomen • Fetal heart rate • Contractions • Measurement of heart rate and movement for 20-30 minutes • Indicated for pregnancy over 28 weeks if: • Baby is not moving as usual • Past due date • Suspicion placenta is not functioning appropriately • High risk pregnancy • Risk: no risk to mom or baby

23. Third Trimester • Biophysical Profile • NST with ultrasound • 5 specific attributes scored • Biophysical attribute • Breathing • Movement • Muscle tone • Heart rate • Amniotic fluid • Total score determines overall health and well being of the baby • Risk: no known risk to mom or baby • Test may be requested if: • Doctor questions the fetal health and well being: • Examination • Maternal/fetal symptoms • High risk pregnancy • Typically performed after 32 wks

24. Third Trimester • Glucose Screening: to test for gestational diabetes or glucose intolerance and asses s the need for intervention (diet and meds) • Two part screening • 1 hour – mom drinks a sweet drink then one hour later has a simple blood draw. • If abnormal then… • 3 hour – baseline fasting blood sugar is drawn on arrival then mom drinks a larger sweet drink then one hour, two hours and three hours later has a simple blood draw.

25. Third Trimester • Group B Strep Infection Screening • Group B Strep is a bacterial infection found in the vagina or rectum • Found in 25% of all healthy, adult women • Test performed by swabbing the vaginal and rectal areas of the pregnant women between 35 and 37 wks • Positive test: simply means you are a carrier, not necessarily actively infected. • This positive result may pass on an infection to the baby during delivery. • Prophylactic antibiotics are typically administered when: • Labor or rupture of membrane is before 37 wks • Rupture of membrane is 18 hours or more before delivery • Fever occurs during labor • Urinary tract infection (caused by GBS) during pregnancy • A previous delivery resulted in a baby with GBS • Risk: no risk to mom or baby

26. Third Trimester • Amniocentesis • Ultrasound guided • Needle is advanced through the abdomen into the amniotic sac to remove a small amount of fluid for testing. • Why amnio so late? • Test for infection in premature rupture of membrane • Severity of fetal anemia • Assess fetal lung maturity

27. Questions??? Thank you All that testing? As easy as a day at the beach 