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*** LISTEN TO THE PODCAST HERE ***

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Initial Prenatal Visit

• Aneuploidy
  • American College of Obstetrics and Gynecology (ACOG) recommends:
    • All women should be offered screening before 20 weeks
    • All women should have the option for having a more invasive procedure instead of screening regardless of maternal age
      • Amniocentesis
      • Chorionic villus sampling
  • Two major categories of screening available
    • Specific maternal serum biomarkers
      • Primarily trisomy 21 and 18
    • Maternal circulation cell-free DNA
      • More sensitive
      • Assesses trisomy 21, 18, 13, and sex chromosome aneuploidies

• Carrier Screening
  • ACOG recommends:
    • All women should be offered carrier screening for cystic fibrosis, spinal muscular dystrophy, thalassemias, and hemoglobinopathies
    • Fragile X
      • All women with a family history of intellectual disability, developmental delay, or autism
    • Each provider develop a screening strategies for ethnic-specific and panethnic populations
  • If there is a (+) screening test in the mother, then the reproductive partner should be offered screening

• Standard Panel Laboratory Screening
  • ABO and Rh Screen
    • RhD(-) women should receive prophylactic anti(D)-immune globin at 28-weeks
  • Complete Blood Count and RBC Indices
    • 1^st Screen for anemia
  • Documentation of Rubella and Varicella Immunity
    • Rubella IgG
    • Varicella IgG
  • Urinalysis and Urine Culture
    • Urine Protein – establish baseline to compare if patient develops pre-eclampsia or eclampsia
    • Untreated, asymptomatic has higher rates of developing pyelonephritis, pre-term birth
  • HIV Screen
    • ACOG recommends “opt-out” approach
  • Hepatitis B
    • HBsAg regardless of immunization status
  • Chlamydia
    • Nucelic Acid Amplification Test (NAAT) of endocervical/vaginal swab or urine
  • Syphilis
    • Can screen with either a non-treponemal or treponemal test, but a (+) screening test is confirmed with a treponemal test

• Selective Screening in 1^st Trimester
  • Thyroid Function – TSH only
  • Overt diabetes screening
    • Obtain HgbA1C if BMI > 25 (23 in Asian Americans) AND at least one of the following:
      • Gestational diabetes in previous pregnancy
      • HgbA1C > 5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
      • 1^st degree relative with diabetes
      • African-American, Latino, Native American, Asian American, Pacific Islander
      • History of cardiovascular disease
      • Hypertension (> 140/90 or on medication)
      • Age > 40yr
      • HDL cholesterol < 35 mg/dL or triglyceride > 250 mg/dL
      • PCOS
      • Physical inactivity
      • Other insulin resistance conditions
    • If HgbA1C > 6.5%, then treat as overt diabetes
    • If HgbA1C (-), then screen again at 24-28 weeks
  • Infections
    • Gonorrhea
      • NAAT from endocervical/vaginal swab
    • Hepatitis C
      • High risk patient should be screened with anti-HCV antibody or HCV RNA
    • Tuberculosis
      • Screen with tuberculin skin test or interferon-gamma release assay (IGRA) only if:
        • Suspicion for recent TB infection
        • Immunocompromised
    • Others
      • Toxoplasmosis, trichomonas, herpes simplex, cytomegalovirus, Zika, and Chagas are available for at risk patients or in endemic regions
  • Lead
    • Women with symptoms of lead exposure or risk factors

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15-24 Weeks

• These are not universal and are options available to mothers
• Quadruple Test
  • Maternal serum alpha-fetoprotein level
  • Unconjugated estriol
  • Human chorionic gonadotropin
  • Inhibin A

• Fetal ultrasound
  • Can be used to screen for neural tube defects and other fetal anomalies, as well as screen the mother for a short cervical length (< 25mm) that can increased her risk of spontaneous preterm birth

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24-28 Weeks

• Gestational Diabetes Screening
  • Two-Step Approach
    • Step One – Screening
      • 50g, one-hour glucose challenge test REGARDLESS of time of day or last meal
    • Step Two – Diagnostic
      • 100g, three-hour oral glucose tolerance test
        • Traditionally diagnostic after 2 elevated values, but newer data suggests that one may be OK
      • 75g, two-hour oral glucose tolerance test
        • Diagnostic after a single elevated value, but patient must be fasting

• Complete Blood Count with iron and folate studies
  • 2^nd anemia screening

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28-36 Weeks

• Sexually Transmitted Infection Screening
  • HIV, syphilis, chlamydia, gonorrhea, hepatitis B and C
  • Based on either previous (+) result or evidence of risk factors

• Screen for group B beta-hemolytic streptococcus
  • Vaginal and rectal swabs
  • (+) results treated with intrapartum prophylaxis

• Screen for Fetal Growth Restrictions (<10^th percentile weight for gestational age)
  • Indicated in third trimester in pregnancies at high risk
    • Infections, fetal anomalies, preeclampsia, gestational HTN and DM, alcohol use, placental/cord abnormalities

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References

1. ACOG Practice Bulletin No. 77: screening for fetal chromosomal abnormalities. Obstetrics and gynecology. 2007; 109(1):217-27. [pubmed]
2. ACOG Practice Bulletin No. 88, December 2007. Invasive prenatal testing for aneuploidy. Obstetrics and gynecology. 2007; 110(6):1459-67. [pubmed]
3. ACOG Committee Opinion No. 752: Prenatal and Perinatal Human Immunodeficiency Virus Testing. Obstetrics and gynecology. 2018; 132(3):e138-e142. [pubmed]
4. Roberts SW, Sheffield JS, McIntire DD, Alexander JM. Urine screening for Chlamydia trachomatis during pregnancy. Obstetrics and gynecology. 2011; 117(4):883-5. [pubmed]
5. Hughes BL, Page CM, Kuller JA. Hepatitis C in pregnancy: screening, treatment, and management. American journal of obstetrics and gynecology. 2017; 217(5):B2-B12. [pubmed]
6. ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstetrics and gynecology. 2018; 131(2):e49-e64. [pubmed]
7. Centers for Disease Control.  Group B Strep (GBS).  https://www.cdc.gov/groupbstrep/guidelines/new-differences.html
8. Bricker L, Medley N, Pratt JJ. Routine ultrasound in late pregnancy (after 24 weeks’ gestation). The Cochrane database of systematic reviews. 2015; [pubmed]

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Question

Polycystic ovarian syndrome (PCOS) can often be a clinical diagnosis due to the classic distinguishing features of hirsutism, obesity, menstrual irregularities, and infertility. What is the classic relationship between FSH and LH in a patient with PCOS?

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You have just assisted with a relatively uneventful spontaneous vaginal delivery of a 38-week newborn to a 29-year-old G1P0001 mother. During your immediate, postpartum maternal assessment, you notice a large amount of vaginal bleeding persisting.

Questions

1. What is the most common cause of this condition?
2. What are the two most important steps in managing this?
3. What are some of the other etiologies to think about?

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Answers

• The most common cause of post-partum hemorrhage is uterine atony and is responsible for up to 75% cases. The amount of bleeding can also be much greater than what is visible due to the flaccid and dilated uterus.
• The two most important steps in managing uterine atony are:
  • Performing bi-manual uterine massage to stimulate contraction
  • Administration of uterotonics
    • ALL women get oxytocin either:
      • 15 units in 250mL of LR
      • 10 units IM
    • If still bleeding after oxytocin:
      • Carboprost tromethamine (Hemabate) 0.25mg IM every 15min up to a max dose of 8mg
      • Methergine 0.2mg IM every 2-4 hours
      • Misprostol 400mcg (SL/buccal/rectal)

• Uterine atony is the most common cause of post-partum hemorrhage, but is responsive to uterotonics in most instances, so it is not the most common cause of massive transfusion. Other etiologies to think about are:
  • Retained placenta/membranes
  • Lacerations or rupture
  • HELLP syndrome
  • Abnormal placentation

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References

1. Bateman BT, Berman MF, Riley LE, Leffert LR. The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesthesia and analgesia. 2010; 110(5):1368-73. [pubmed]

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You have just assisted with a relatively uneventful spontaneous vaginal delivery of a 38-week newborn to a 29-year-old G1P0001 mother. During your immediate, postpartum maternal assessment, you notice a large amount of vaginal bleeding persisting.

Questions

1. What is the most common cause of this condition?
2. What are the two most important steps in managing this?
3. What are some of the other etiologies to think about?