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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
what is particularly important for accurate screening results
accurate gestational age, determined by first trimester dating U/S
26
what does maternal AFP screen for
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)
27
in which women should you offer a maternal serum "AFP only" screening for ONTDs?
women with a BMI 40 or above women with limited access to 18-20 week U/S
28
how do you counsel women about prenatal screening
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
29
when should you ideally send women for the quad/second trimester portion of their screening
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
30
does screening provide a definitive diagnosis
no, only an estimation of risk
31
when can you do NIPT
from 10 weeks onwards
32
do you need to do a separate dating U/S if first trimester NT is done
no
33
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
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
if a woman pays for NIPT, and its negative, should they be offered an NT U/S
no
35
can anyone choose to get CVS/amnio
no... CVA and amio for fetal karyotyping will not be offered without prior screening except for certain women
36
who is eligible for CVS/amnio without prior screening
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
what does a NT screening of 3.5 mm or above suggest
increased risk of congenital heart defects, genetic syndromes, and chromosomal abnormalities other than common aneuploidies referral to medical genetics is recommended
38
what is the preferred method for calculating gestational age
first trimester dating U/S (are not required though)
39
how do you manage a positive NIPT screen
refer to medical genetics amniocentesis is recommended for diagnostic confirmation of the positive NIPT prior to any irrevocable obstetrical decision
40
what do you tell a woman with a positive IPS/SIPS/quad who goes on to have a negative NIPT
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
who should be offered a second trimester detailed ultrasound
all pregnant women
42
when is the second trimester detailed U/S done
18-20 weeks
43
when should the initial prenatal visit occur
6-12 weeks
44
how do you determine estimated date of conception
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
what are the symptoms of pregnancy
``` amenorrhea breast tenderness nausea, vomiting fatigue urinary frequency ```
46
what should you discuss at first prenatal visit
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
what blood tests should be done at the initial visit
``` 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
why should you ask about travel history at a prenatal visit
Zika--risk of microcephaly
49
what should you ask on past surgical history in a prenatal visit
c sections pelvic surgeries anesthetic problems abdominal, back, CNS, eye (might be affected with valsalva) or cervical surgery
50
what to ask on OB history
``` 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
what to ask on gyne history
date of last pap any abnormal paps and results from those investigations previously or currently at high risk for STI
52
what should be asked about on subsequent prenatal visits
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
what are the four cardinal symptoms to ask about in pregnancy
ABCD fetal Activity (beginning 18-20 weeks) Bleeding Cramping fluid Discharge
54
what are red flags to watch out for in subsequent prenatal visits
absence or decrease in fetal movements beyond 20 weeks GA bleeding contractions HTN maternal illness
55
what meds to recommend people take in pregnancy
folic acid (best if taken 3 months prior to conception) prenatal vitamins vitamin D calcium
56
list the teratogen meds to ask about in pregnancy--what do you do if your patient is on one of these?
``` 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
what to ask about on family history at a prenatal visit
``` HTN DM VTE multiple gestations stillbirth chromosomal abnormalities structural abnormalities syndrome and genetic abnormalities ```
58
what to ask on social history at the prenatal visit
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
list risk factors that increase complications in pregnancy
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
what physical exam should be done on the initial visit
complete physical exam --BP, HR, HEENT, breast, CV, abdo, reflexes, varicosities/extremities, perineal/pelvic exam measure baseline BMI
61
what physical exams should be done on subsequent visits
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
how do you measure SFH
measure from pubic symphysis to uterine fundus should be plus or minus 2 cm of GA between GA 20-40 weeks
63
how do you determine fetal lie
leopolds maneuvers
64
when do you start listening for fetal HR
12 weeks with dopplers
65
a pregnant woman presents with vaginal bleeding--> what should you do before doing a digital vaginal exam
an ultrasound to confirm position of placenta and make sure its not previa
66
when should you do gestational DM screen
24-28 weeks
67
what tests other than blood tests should be done on initial prenatal visit
urine R&M, C&S pap test if needed urine NAAT for gonorrhea and chlamydia
68
when should the GBS swab be done
week 35-37
69
what urine tests should be done in subsequent routine prenatal visits
urine dip for protein and glucose
70
what vaccines are contraindicated in pregnancy
MMR | HPV
71
what vaccines are recommended and given routinely to all pregnant women
influenza inactivated DTaP--vaccinate between weeks 27-36 in EACH pregnancy
72
what vaccines are safe in pregnancy and should be given if required
hep A hep B meningococcal pneumococcal
73
how can maternal N/V be managed
frequent small meals avoid triggering foods Diclectin PO gravol
74
how do you manage a woman that is Rh negative in prenatal care
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
should you recommend bed rest
NOT therapeutic in treating or preventing pre term labour and GHTN and may be harmful
76
when should you start checking cervix for dilation
36 weeks
77
how often should you see pregnant women in follow up
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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