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LMCC Part II > Prenatal Visit > Flashcards

Prenatal Visit Flashcards

1
Q

what do prenatal genetic tests screen for

A

estimate risk for down syndrome, trisomy 21 and open neural tube defects

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2
Q

what factors determine what screening is offered

A

gestational age at time of presentation

maternal age at time of delivery

whether pregnancy is singleton or twin gestation

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3
Q

to whom is nuchal translucency (NT) offered

A

women at higher risk of having a fetus with down syndrome or trisomy 18

women with twin pregnancies

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4
Q

what is SIPS

A

“serum integrated prenatal screening”

should be offered to ALL pregnant women in BC

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5
Q

what is IPS

A

“integrated prenatal screen”

this is SIPS in combo with nuchal translucency ultrasound

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6
Q

who should be offered IPS (NT with serum screen)

A
  1. women 35 years or older at EDD
  2. women with twin pregnancies
  3. women pregnant following IVF with intracytoplasmic sperm injection (ICSI)
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7
Q

who should be offered SIPS

A

all pregnant women in BC

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8
Q

which patients should be offered amniocentesis

A

women 40 or older with singleton pregnancy
or
women 35 or older with multiple gestation pregnancy

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9
Q

is NIPT covered or out of pocket

A

usually out of pocket but is provincially funded for some women

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10
Q

for which women is NIPT provincially funded

A
  1. women with a positive screen result from IPS, SIPS or the quad tests
  2. women who have a documented history of a previous child or fetus with down syndrome, trisomy 18 or trisomy 13
  3. women whose risk of down syndrome is equal to or greater than 1/300 based on the finding of the U/S marker(s) and results of SIPS/IPS/quad
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11
Q

list the options available for prenatal genetic screening

A 
SIPS
IPS
quad
NIPT
detailed second trimester U/S
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12
Q

what are some of the factors that go into determining risk for down sydrome, trisomy 18, and open neural tube defects

A

biochemical serum markers from blood work

maternal age and ethnicity

maternal weight

maternal diabetic status

maternal smoking

NT U/S measurement if available

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13
Q

what does SIPS involve

A

measurement of 1st trimester PAPP-A and second trimester quad markers

two separate blood tests

quad markers are alpha feto-protein (AFP), unconjugated estriol (uE3), human chorionic gonadotropin (hCG) and inhibin-A

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14
Q

when is the first test for SIPS drawn

A

first blood test is collected between 9-13+6 weeks (best 10-11 weeks)

this is the PAPP-A test

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15
Q

when is the second test for SIPS drawn

A

14-20 weeks (best 15-16 weeks)

this is the quad test

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16
Q

when are the SIPS results available

A

10 days after the second blood test (the quad)

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17
Q

what markers are part of the quad screen

A

quad markers are:
alpha feto-protein (AFP)

unconjugated estriol (uE3)

human chorionic gonadotropin (hCG)

inhibin-A

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18
Q

what does IPS involve

A

first trimester PAPP-A and NT U/S plus the quad in the second trimester

(blood test timing is the same as SIPS)

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19
Q

when is the NT done for IPS

A

11-13+6 weeks (best 12-13 weeks)

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20
Q

when are the results from IPS available

A

10 days after the second blood test (same as SIPS)

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21
Q

what happens if the NT U/S measurement is high

A

results in a positive screen

counselling and further testing are offered PRIOR TO completing the second blood test

further tests: (and/or)
NIPT
chorionic villi sampling (CVS)
amniocentesis

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22
Q

which women should be offered the quad screen

A

this should only be offered to women who present late for prenatal care (2nd trimester) as SIPS and IPS have better screening performance with lower false positive rates so if possible, these should be offered

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23
Q

what is NIPT

A

non invasive prenatal testing

blood test which analyzes free fetal DNA circulating in maternal blood

tests for down syndrome, trisomy 18, trisomy 13, sex aneuploidy

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24
Q

how effective is NIPT

A

detection rate for down syndrome in singleton pregnancies approaching 100% and 97% for trisomy 18

false positives are 0.1%

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25
Q

what is particularly important for accurate screening results

A

accurate gestational age, determined by first trimester dating U/S

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26
Q

what does maternal AFP screen for

A

open neural tube defects

only has a detection rate of 70%

the detailed U/S at 18-20 weeks has a higher detection rate for ONTDs (thus if the woman gets NIPT, or chooses not to screen for down syndrome, better to screen for ONTDs by this detailed U/S than by the serum AFP test)

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27
Q

in which women should you offer a maternal serum “AFP only” screening for ONTDs?

A

women with a BMI 40 or above

women with limited access to 18-20 week U/S

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28
Q

how do you counsel women about prenatal screening

A

it is THEIR CHOICE to undertake screening

information about prenatal genetic screening should be given to pregnant women at the first contact with a healthcare professional–this should occur in the first trimester, ideally prior to 10 weeks GA in order to ensure that the appropriate early tests are performed if desired

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29
Q

when should you ideally send women for the quad/second trimester portion of their screening

A

as early as possible within the alloted timeframe (14-20+6 weeks… best at 14-15 weeks)

this allows for earlier results and f/up (NIPT or amnio) if necessary

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30
Q

does screening provide a definitive diagnosis

A

no, only an estimation of risk

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31
Q

when can you do NIPT

A

from 10 weeks onwards

32
Q

do you need to do a separate dating U/S if first trimester NT is done

A

no

33
Q

if a woman has a personal or family history that increases risk of fetus with chromosomal abnormalities other than down syndrome/trisomy 18/trisomy 13 what should be offered

A

CVS or amnio depending on time of presentation

a referral early in pregnancy to medical genetics in vancouver or victoria (also for high risk of the 3 trisomies)

34
Q

if a woman pays for NIPT, and its negative, should they be offered an NT U/S

A

no

35
Q

can anyone choose to get CVS/amnio

A

no… CVA and amio for fetal karyotyping will not be offered without prior screening except for certain women

36
Q

who is eligible for CVS/amnio without prior screening

A

women 40 or older at EDD

women at increased risk of having a fetus with a chromosomal abnormality

women with multiple gestations who are 35 or older at EDD

37
Q

what does a NT screening of 3.5 mm or above suggest

A

increased risk of congenital heart defects, genetic syndromes, and chromosomal abnormalities other than common aneuploidies

referral to medical genetics is recommended

38
Q

what is the preferred method for calculating gestational age

A

first trimester dating U/S (are not required though)

39
Q

how do you manage a positive NIPT screen

A

refer to medical genetics

amniocentesis is recommended for diagnostic confirmation of the positive NIPT prior to any irrevocable obstetrical decision

40
Q

what do you tell a woman with a positive IPS/SIPS/quad who goes on to have a negative NIPT

A

these women would no longer qualify for amniocentesis-the woman should be reassured as the negative predictive value of NIPT is very high (if its negative, were pretty sure its negative)

41
Q

who should be offered a second trimester detailed ultrasound

A

all pregnant women

42
Q

when is the second trimester detailed U/S done

A

18-20 weeks

43
Q

when should the initial prenatal visit occur

A

6-12 weeks

44
Q

how do you determine estimated date of conception

A

either dating U/S
and/or
based on LMP

nageles rule: 1st day of LMP + 7 days - 3 months
–> then add or minus days above or below a 28 day cycle

45
Q

what are the symptoms of pregnancy

A 
amenorrhea
breast tenderness
nausea, vomiting
fatigue
urinary frequency
46
Q

what should you discuss at first prenatal visit

A
  1. establish estimated date of conception–U/S booking or nageles rule
  2. full past medical, surgical, obstetric, family, social history
  3. full medication history and current meds and allergies
  4. planned or unplanned pregnancy? –tactfully assess desire to continue with pregnancy and be supportive of the patients choice
  5. symptoms of pregnancy
  6. discuss pregnancy blood work and investigations
47
Q

what blood tests should be done at the initial visit

A 
routine--> 
CBC
ABO/Rh
blood antibodies
HBsAg
syphilis serology
HIV serology
rubella titre
varicella immune status
book detailed U/S for 18-20 weeks

discuss genetic screens

48
Q

why should you ask about travel history at a prenatal visit

A

Zika–risk of microcephaly

49
Q

what should you ask on past surgical history in a prenatal visit

A

c sections
pelvic surgeries
anesthetic problems
abdominal, back, CNS, eye (might be affected with valsalva) or cervical surgery

50
Q

what to ask on OB history

A 
previous pregnancies
dates of delivery
GA at delivery 
delivery type
gender
birth weight
complications during pregnancy, delivery or postpartum for mother and infant
childs health
abortions--spontaneous or therapeutic
51
Q

what to ask on gyne history

A

date of last pap
any abnormal paps and results from those investigations
previously or currently at high risk for STI

52
Q

what should be asked about on subsequent prenatal visits

A

inquire about patients well being

routine and special investigations

monitor for fetal well being

monitor for signs of pregnancy complications

DO NOT change assigned GA–most accurate in first trimester

FOUR CARDINAL SYMPTOMS (ABCD)

53
Q

what are the four cardinal symptoms to ask about in pregnancy

A

ABCD

fetal Activity (beginning 18-20 weeks)

Bleeding

Cramping

fluid Discharge

54
Q

what are red flags to watch out for in subsequent prenatal visits

A

absence or decrease in fetal movements beyond 20 weeks GA

bleeding

contractions

HTN

maternal illness

55
Q

what meds to recommend people take in pregnancy

A

folic acid (best if taken 3 months prior to conception)
prenatal vitamins
vitamin D
calcium

56
Q

list the teratogen meds to ask about in pregnancy–what do you do if your patient is on one of these?

A 
valproic acid
ACEi
warfarin
tegretol
isoretinoin 
NSAIDs (beyond 20 weeks)

stop and substitute ASAP, document exposure history and timing, goal use of safest drug at the lowest dose, at the safest time during pregnancy

57
Q

what to ask about on family history at a prenatal visit

A 
HTN
DM
VTE
multiple gestations
stillbirth
chromosomal abnormalities
structural abnormalities
syndrome and genetic abnormalities
58
Q

what to ask on social history at the prenatal visit

A

occupation–mother, father, those at home

EtOH
smoking
illicit drugs
IVDU

partner info, stability, current living situation

safety at home/DOMESTIC VIOLENCE

diet–recommend reduce caffeine, exercise

59
Q

list risk factors that increase complications in pregnancy

A

mother younger than 17 or older than 35

pre existing medical conditions like DM, HTN, CKD, SLE, APLAS

poor or lack of prenatal care

previous c section

fetal factors–> multifetal, ART use, placenta previa

60
Q

what physical exam should be done on the initial visit

A

complete physical exam
–BP, HR, HEENT, breast, CV, abdo, reflexes, varicosities/extremities, perineal/pelvic exam

measure baseline BMI

61
Q

what physical exams should be done on subsequent visits

A

weight and BP –expected weight gain varies by starting BMI

symphyseal fundal height–plot on prenatal growth curve
–> measure from pubic symphysis to uterine fundus

fetal position (starting at 28-32 weeks)–> leopolds maneuvers to determine the lie of the fetus; confirm presentation of fetus at 36 weeks

determine fetal HR–> starting at 12 weeks using dopplers

62
Q

how do you measure SFH

A

measure from pubic symphysis to uterine fundus

should be plus or minus 2 cm of GA between GA 20-40 weeks

63
Q

how do you determine fetal lie

A

leopolds maneuvers

64
Q

when do you start listening for fetal HR

A

12 weeks with dopplers

65
Q

a pregnant woman presents with vaginal bleeding–> what should you do before doing a digital vaginal exam

A

an ultrasound to confirm position of placenta and make sure its not previa

66
Q

when should you do gestational DM screen

A

24-28 weeks

67
Q

what tests other than blood tests should be done on initial prenatal visit

A

urine R&M, C&S
pap test if needed
urine NAAT for gonorrhea and chlamydia

68
Q

when should the GBS swab be done

A

week 35-37

69
Q

what urine tests should be done in subsequent routine prenatal visits

A

urine dip for protein and glucose

70
Q

what vaccines are contraindicated in pregnancy

A

MMR

HPV

71
Q

what vaccines are recommended and given routinely to all pregnant women

A

influenza inactivated

DTaP–vaccinate between weeks 27-36 in EACH pregnancy

72
Q

what vaccines are safe in pregnancy and should be given if required

A

hep A
hep B
meningococcal
pneumococcal

73
Q

how can maternal N/V be managed

A

frequent small meals
avoid triggering foods
Diclectin PO
gravol

74
Q

how do you manage a woman that is Rh negative in prenatal care

A

Rhogam routinely at 28 weeks and with episodes of intrapartum hemorrhage

re-administer at 40 weeks if undelivered and then post partum if required

75
Q

should you recommend bed rest

A

NOT therapeutic in treating or preventing pre term labour and GHTN and may be harmful

76
Q

when should you start checking cervix for dilation

A

36 weeks

77
Q

how often should you see pregnant women in follow up

A

every 4 weeks until 28 weeks

every 2 weeks from 28-36 weeks

weekly from 36 weeks until delivery

LMCC Part II (52 decks)

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