maternal screening in pregnancy

EXPERT GROUP
DR NARENDRA MALHOTRA
DR MALAARORA
DR RANJANA KHANNA
DR ABHA RANI SINHA
DR PRAGYA MISHRA
DR NAVNEET MAGON
DR GANPAT SAWANTA

Reference Material
• New WHO guidelines on antenatal care –
Systematic review BJOG 2016;123:519-28
• Guidelines by Government of western
Australia
• SOGC guideline on Prenatal Screening
• RCOG / NICE Guidelines

Why Screen ?
1.Triage mothers to High Risk & Low Risk
2.Prevent Maternal Complications
3.Screen the fetus for
• Chromosomal errors
• Structural Defects
• Growth abnormalities
4.Decide the time and mode of safe
delivery

ADD SCREENING FOR N.C.D.HERE
THE PYRAMID OF ANTENATAL CARE
Post delivery continued screening

Routine Antenatal Care 1990s…….
Early scan to diagnose
pregnancy & dating
22-24 wks
Fetal defects
Anomaly scan

Routine Antenatal Care 2005
11-14 wks
Fetal defects
20-23 wks
P I P I P
The great
Ob syndrome

Routine Antenatal Care 2010
11-13+6 wks
Fetal defects
Chemical markers Major
Cardiac defects
Uterine artery Doppler
20-23 wks
Anomaly scan

FOGSI OLD CHECK LIST OF 2009,MODIFIED IN 2017 AT FOGSI T.O.G.

First Trimester
Second Trimester
Third Trimester

Body Mass Index – If high
•Prevent further weight gain
•Institute Life style modifications
•Medical Therapy – Metformin
•Nutrition Therapy – High fibre diet
•Daily Exercise
•Prepare for safe delivery

General Examination
• Heart – Murmurs
• Lungs – Rhonchi
• Breast – Lumps / Nipples
• Abdomen – Scars / Lumps
•Per Speculum – Discharge / Polyp / Erosion
LBC / HPV
• Anus – Sentinel Pile

Blood Pressure
• Hypertension – BP in both arms
Sitting position
Dissappearance of korotkov
• Hypotension – increase sodium/ potassium intake
• Screening test for PIH
 Placental Growth Factor (PlGF)
 S Flt
 s endoglin
 Uterine artery doppler flow indices

Screening for Anaemia
• Complete Blood count
• Peripheral Smear
• If Microcytic Hypochromic
Iron studies – Ferritin / Total Iron / TIBC
Haemoglobin Electrophoresis
• If Normocytic / Macrocytic
Serum Vitamin B12
Serum / Red cell Folate
Reticulocyte count

Blood group & Rhesus Antibodies
• If Rhesus Negative
• Partners Blood group – If negative –
• If positive – Indirect Coombs test
• If positive – Cordocentesis & fetal blood
transfusion with Rh negative blood at
periodic intervals
• Deliver at 34 weeks

Endocrine Screening
• Thyroid function test
• If abnormal, thyroid antibodies
• In PCO – screen for GDM early (HbA1C)
• If galactorrhea – Prolactin
• Serum Vitamin D
• Relaxin ?

Infection Screen
• Complete blood count /ESR
• Rubella antibodies
• Urine routine & microscopy
• Mid stream urine culture
• High Vaginal / Endo cervical swab /Wet Prep /
Vaginal pH / Chlamydia antibodies
(SOLVS + FVU PCR)
• HIV / Hep B / Hep C / VDRL

Various Integrated screening in
strategies (1st and 2nd trim)
Main strategies:
• Fully Integrated
• Step-wise sequential
• Contingent screening
NT
, PAPP
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NIPT
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Fb-hCG, AFP, uE3, (± Inhibin)
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CVS
Risk estimatH
e igh risN
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T
VS
Borderline risk
No further
screening
LR HR

First trimester screening for
Preeclampsia
Maternal serum PIGF,
Mean arterial Blood pressure
- Implantation
- Maternal artery remodelling
Detection rate – 90%
0
10
20
30
False
positive
(%)
Doppler
12%
30%
PP13
9%
Doppler
& PP13

Non Invasive Prenatal Testing (NIPT)
• NIPT – 9 weeks onwards
• At least 4% fetal fraction to be identified
• Twin Pregnancy – confusing results
• Vanishing twin – confusing results
• If positive – CVS / Amniocentesis

CVS
•11-14 weeks
•Transcervical
•Check for chorionic villi under
microscope
•Risk of miscarriage 1%
•Need is obviated now due to NIPT

Amniocentesis
•15-18 weeks
•Risk of miscarriage < 1%
•To confirm diagnosis in positive
integrated screen and/or positive NIPT
•To screen known carriers for
chromosomally abnormal fetus

FIRST TRIMESTER
SCREENING FOR
CHROMOSOMAL
ANOMALIES

Screening in the 1st trimester
• Time window: 8 - 14 weeks
• Ultrasound Marker:
• NT
• Biochemical markers:
• PAPP-A
• Fb-hCG
• Marker combination:
• Combined test: NT, PAPP-A, Fb hCG

Screening for Trisomy 21 at 11- 14 weeks
2-stage (contingency) screening- UK system
USG (N.T.) AND DUAL MARKER FOR ALL
Fetal NT and
free BhCG and
PAPP-A at 12 wks
Very high risk
Very low risk
CVS
Reassure
Borderline
risk
Further
screening
Nasal bone
DV, TR

Screening for Trisomy 21 at 11- 14 weeks for
India
2-stage (contingency) screening proposed
RISK ESTIMATE BY ONLY USG N.T. AND OTHER MARKERS
Fetal NT
Nasal bone and
ductus venosus
tricuspid
regurgitation at 12
wks
Very high risk
Very low risk
CVS
Reassure
Borderline
risk
Further
screening
Free B hCG
PAPP-A
THIS WILL SAVE
TIME
MONEY
OPTIMUM USE OF OUR
SKILL
DOUBLE MARKER
TEST
Scan 20w NIPT

• MA+ NIPT(OPTIONAL)
• Dual Marker
• NT + NB + TR + DV
First
trimester
• Quad Marker
• Genetic Sonogram
Second
trimester
Integrated1
st and2nd trimesterscreening
DR – 97%
FPR – 2.5%

SO PROPOSAL IS INDIAN
CONTINGENT SCREEN
OR
INTEGRATED FIRSTAND
SECOND TRIMESTER
SCREEN
COMBINED FIRST TRIMESTER SCREEN
FOR RISK ESTIMATE…….
FOLLOWED BY COMBINED 2ND
TRIMESTER RISK SCREENING

COMBINED SCREENING & RISK ESTIMATION IN FIRST
TRIMESTER

1LOW LEVELS PREDICT PRE ECCLAMPSIA
2 LOW RISK NO FURTHER TEST (1 : 1000)
INTERMEDIATE RISK (100 : 999) TO PROCEED TO SECOND TRIMESTER SCREENING VS NIPT
HIGH RISK (1 : 99) TO GO FOR CVS / NIPT
ANTENATAL CHECKLIST
First Trimester Recommended Preferable
weight BMI
Blood pressure Mean Arterial Pressure
Haemoglobin Complete blood count/ Peripheral smear /
Hb Electrophoresis / HPLC
Blood group ABO & Rh (both partners)
Urine routine MSU culture
VDRL/ Hep B / HIV HCV / Rubella IgG
TSH Thyroid function test / Thyroid Antibodies
Vitamin D
DIPSI test 75gms 2 hours blood sugar Hb A1C / OGTT/ 6 point blood sugar test
Dating scan + NT
Double marker (free beta
HCG + PAPP A1 )
(Contingent Screen2
Cervical length
Uterine artery Doppler
NIPT
Placental Growth Factor
(PLGF)
Per speculum exam Pap Smear, Bacterial vaginosis &
Chlamydia screen

CERVICAL LENGTH SCREENING
ROUTINE TO PREVENT PRETERM
LABOUR AND FOR GUIDELINE FOR
CX STITCH
• ASYMPTOMATIC SINGLETON PREGNANCYATVS CL <25
MM IN SECOND TRIMESTER
• SCREEN AT 11-13 WEEKSAND THEN AT 22-22 WEEKS
RECENT EVIDENCE SAYS CX STITCH DOES NOT HELP AND
PROGESTERONE MAY BE THE ONLY TREATMENT OPTION
HERE.ROUTINE MCDONALD STITCH PRACTISE SHOULD BE
INDIVIDUALISED

Second Trimester Recommended Preferable
18-24 weeks Repeat bloods (Hb /
blood sugar / TSH) &
urine test as indicated
Quadruple OR Triple
marker
NIPT
Anomaly scan 3D/4D scan/ Fetal
Echo
Uterine artery
Doppler
Cervical length
DIPSI screen 75 gms 2
hour blood sugar
6 Points Blood
Sugar HbA1C

Sequential Screening
•Quadruple marker – 15-18 weeks
•NIPT 9 week onwards
•Amniocentesis – 15 week onwards

COMBINED 2ND TRIMESTER SCREENING

Screening for GDM
• HbA1C
• DIPSI one step screen 75 gms 2
hour
• Cut off of 140 mg/dl
• At 24 to 28 weeks
• Repeat at 32 weeks in high risk
women i.e Polyhydramnios /
previous GDM / Parents &
siblings diabetic

Screening for PIH
• Blood Pressure
• Water Retention – edema / rapid
weight gain
• Micro albuminuria
• Spot test – Urine Protein /Creatinine
ratio
• Ratio of PlGF / sFlt
• LDH raised in HELLP Syndrome
• Renal artery doppler

Vaccination
• Tetanus Toxoid – ONE DOSE
• Tdap –SECOND DOSE AT 24 WEEKS
• Influenza vaccine 24 weeks onwards
• hpB can be given if not immunised
• Targetted Vaccine in case of travel to
endemic areas
• Post partum – HPV vaccine

Abbreviations
Hb Haemoglobin
TSH Thyroid stimulating hormone
HbA1C Haemoglobin A1C
Scan,
NIPT Non invasive prenatal testing
plasma protein A
PlGF Placental growth factor
HCV Hepatitis C virus
HIV Human Immune defeciency virus
chromatography
GCT- Glucose Challenge Test
OGTT Oral glucose tolerance test
NT Scan- Nuchal Translucency
PAPP A- PregnancyAssociated
VDRL Venereal disease reference
Hep B hepatitis B virus
HPLC high performance liquid
Third
Trimester
Recommended Preferable
24 weeks
onwards
Repeat DIPSI Screen
TSH/Hb/Urine
HbA1C
Growth scan with liquor volume
& placental localisation
Fetal Doppler
velocimetry
Fetal movement count CTG (NST)
(6 in 2 hours) Modified
biophysical
Score
Doppler
velocimetry

INFECTION SCREEN
• GBS – Is routine screening required prior to
delivery ?
• Pelvic assessment – Does it improve your
decision for normal delivery ?
• Pelvic relaxation techniques / exercises like
walking / squatting / butterfly

NON USG SCREENING
FOR FETAL WELL
BEING

Cardiotocography
• Non Stress test vs Oxytocin Stress test
• When to start ? Post viability period 30
weeks
• How often to do ? Once a week
• What are the omnious signs –
Lack of BTB variation
Variable deaccelerations of cord
compression
Late deacceleration of fetal hypoxia
• Supplement with ST waveform analysis
• Fetal cord blood pH during labour

Recording
•Every kick / roll is 1 movement
•Count 10 movements everyday
•Should be around 6 in 1 hour
•If < 6 movements in 2 hours
•Call doctor & come for CTG / USS
assessment

About baby’s movements
An active baby is usually a healthy baby. You
will feel your baby stretch, kick, roll and turn
every day. Some babies are more active than
others. All babies have periods of sleep during
which they are not as active. You will get to
know your baby’s pattern of movements and
when your baby is most active.
You should feel your baby’s movements
throughout the day, each day from 28 weeks of
pregnancy until the baby is born.
When during my pregnancy should I count
my baby’s movements?
Your health care provider may ask you
to count your baby’s movements once
every day.
If you think there is a decrease in your
baby’s movements this is an important sign that
your baby may not be well. Count your baby’s
movements to be sure that you feel at least 6
movements in 2 hours.
Reference:
Society of Obstetricians and Gynaecologists of Canada (2007).
Fetal Health Surveillance : Antepartum and Intrapartum Consensus
Guideline. Journal of Obstetrics and Gynaecology Canada. 29(9).
FETAL MOVEMENT
COUNT CHART
PLEASE BRING THIS CHART WITH YOU EACH
TIME YOU SEE THE DOCTOR/MIDWIFE
IMPORTANT PHONE NUMBERS:
DOCTOR:
MIDWIFE:
HOSPITAL:
DUE DATE:
OTHER INSTRUCTIONS:
For 24-hour nurse advice and health information call
Health Link Alberta:
1-866-408- LINK (5465)– Toll Free
In Calgary call 403-943- LINK (5465)
In Edmonton call 780-408-LINK (5465)
ADDRESS:
NAME:
HS0001-132 (2012/11)
How do I count my baby’s movements?
• Get into a comfortable position – lying on
your side or sitting. Place one or both of your
hands on your abdomen.
• Count each time that you feel your baby
move. If you feel many movements all at
once, count each movement that you feel.
• Write down the date and the time that you
start counting on the fetal movement chart.
• Make a mark on the chart each time your baby
moves.
• Stop counting when you have counted 6
movements.
• Write down the time you stopped counting.
• Do not count for more than 2 hours
What if I don’t feel 6 movements in 2 hours?
Count your baby’s movements once a day. You
should feel 6 or more movements in 2 hours.
If you count fewer than 6 movements in 2 hours
do not wait. Go to the hospital or birthing unit.
Your baby’s heart rate and movements will be
checked using a fetal monitor. This is called a
non-stress test or NST.
If you live too far from a hospital or birthing
unit, immediately contact your health care
provider for advice.

TWEAK Screening for alcoholism
• T – Tolerance (No of drinks one can hold)
• W- Worry about drinking
• E – Eye opener
• A- Amnesia
• K/C – Cut down on drinking
• To screen for fetal alcohol syndrome

• Antepartum fetal surveillance is the assessment of
fetal well being in utero before the onset of labor
• Early detection of fetus at risk so that timely
management to prevent further deterioration
• Also find out normal fetuses and avoid unnecessary
interventions
• Very high negative predictive value
• Very low positive predictive value

FETUS AT RISK
• PRE TERM
• POST TERM
• IUGR
• THICK MECONIUM
WITH SCANTY
FLUID
• INTRAUTERINE
INFECTION
• INTRAPARTUM
BLEEDING
FETUS AT
RELATIVE RISK
INJUDICIOUS USE OF
OXYTOCIN
EPIDURAL IN A CASE WITH
SOME COMPROMISE
DIFFICULT INSTRUMENTAL
DELIVERY/ MACROSOMIA/
MALPRESENTATION
ACUTE EVENTS (CORD
PROLAPSE, ABRUPTION,
SCAR RUPTURE)
SUSPICIOUS/ ABNORMAL
ADMISSION TEST

Admission assessment
Are any risk factors present?
Maternal problems
• Previous LSCS
• Pre-eclampsia
• Post-term pregnancy (>42
weeks)
• Prolonged membrane rupture
(>24 hours)
• Induced labour
• APH
• Other maternal disease
Fetal problems
• Growth restriction
• Prematurity
• Oligohydramnios
• Abnormal dopplers
• Multiple pregnancy
• Meconium stained liquor
• Breech presentation

INDICATION OF FETAL SURVEILLANCE
•Maternal conditions
• Hypertension
• Diabetes mellitus
• Heart Disease
• Chronic renal disease
• Acute febrile illness
• Pneumonia /asthma
• Epilepsy

• Collagen vascular disease
• Sickle cell disease
• Antiphospholipid syndrome
• Drug Abuse
• FETAL CONDITIONS
• Fetal growth restriction
• Rh isoimmunisation
• Fetal Cardiac arrythmia

• Hydrops fetalis
• Fetal infections
• PREGNANCY RELATED CONDITIONS
• Preeclampsia
• Multiple pregnancy
• Post term pregnancy
• Decreased fetal movements
• Abnormal placentation
• Placental abruption

• Oligohydramnios
• Polyhydramnios
• Unexplained stillbirth in a previous pregnancy
• Cholestasis of pregnancy
• PROM
• Poorly controlled Gestational Diabetes mellitus

The Various Methods of Antepartum
Fetal Surveillance
1) Clinical assessment by uterine growth
2) Fetal movement count by the mother
3) Ultrasound for fetal growth
4) Non stress test and cardiotocography
5) Vibroacoustic stimulation test
6) Contraction stress test
7) Nipple stimulation test
8) Biophysical profile
9) Modified biophysical profile
10) Doppler studies
11) Fetal lung maturation studies
12) Placental grading

Check list made a few years back…….NOW TO BE MODIFIED

SCREENING IN PREGNANCY
At booking (Recommended 3ANC) [Preferable 5]
General Physical exam Heart / Lungs / Breast /
Abdomen
In all trimesters
• Maternal weight /BMI
• Blood Pressure / Mean Arterial Pressure
• Urine dipstick (albumin sugar)

Abbreviations
Hb Haemoglobin GCT- Glucose Challenge Test
OGTT Oral glucose tolerance test
NT Scan- Nuchal Translucency
TSH Thyroid stimulating hormone
HbA1C Haemoglobin A1C
Scan,
NIPT Non invasive prenatal testing
plasma protein A
PlGF Placental growth factor
HCV Hepatitis C virus
HIV Human Immune defeciency virus
chromatography
PAPP A- PregnancyAssociated
VDRL Venereal disease reference
Hep B hepatitis B virus
HPLC high performance liquid
Third
Trimester
Recommended Preferable
24 weeks
onwards
Repeat DIPSI Screen
TSH/Hb/Urine
HbA1C
Growth scan with liquor volume
& placental localisation
Fetal Doppler
velocimetry
Fetal movement count CTG (NST)
(6 in 2 hours) Modified
biophysical
Score
Doppler
velocimetry

Abbreviations
• Hb Haemoglobin
• GCT- Glucose Challenge Test
• TSH Thyroid stimulating hormone
• OGTT Oral glucose tolerance test
• HbA1C Haemoglobin A1C
• NT Scan- Nuchal Translucency Scan,
• NIPT Non invasive prenatal testing
• PAPPA- Pregnancy Associated plasma protein A
• PlGF Placental growth factor
• VDRL Venereal disease reference
• HCV Hepatitis C virus
• Hep B hepatitis B virus
• HIV Human Immune defeciency virus
• HPLC high performance liquid chromatography

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