ADBHUT MATRATVA ANTENATAL SCREENING

ADBHUT MATRATVA ANTENATAL SCREENING

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  ANTENATAL SCREENING
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  Reference Material • NewWHO 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
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  OUR PUBLICATION ATFIGO
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  ABSTRACT
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  FIGO GUIDELINES PRESENT8 GOOD PRACTICE ADVISES • 1.SCREENING FOR CHROMOSOMAL ABNORMALITIES AND NIPD • 2.PRECONCEPTIONAL FOLIC ACID FOR THE PREVENTION OF NEURAL TUBE DEFECTS • 3.CERVICAL LENGTH AND PROGESTERONE FOR THE PREDICTION AND PREVENTION OF PRETERM BIRTH • 4. & 5.MAGNISIUM SULPHATE USE IN OBSTETRICS • 6.ULTRASOUND EXAMINATION IN PREGNANCY • 7.THYROID DISEASE IN PREGNANCY • 8.HYPERGLYCEMIA IN PREGNANCY
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  WHY SCREEN ?
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  Why Screen ? 1.Triagemothers 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
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  ADD SCREENING FORN.C.D.HERE THE PYRAMID OF ANTENATAL CARE Post delivery continued screening
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  Routine Antenatal Care1990s……. Early scan to diagnose pregnancy & dating Fetal defects 22-24 wks Anomaly scan
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  Routine Antenatal Care2005 11-14 wks Fetal defects 20-23 wks P I P I P The great Ob syndrome
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  Routine Antenatal Care2010 11-13+6 wks Fetal defects Chemical markers Major Cardiac defects Uterine artery Doppler 20-23 wks Anomaly scan
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  FOGSI OLD CHECKLIST OF 2009,MODIFIED IN 2017 AT FOGSI T.O.G.
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  First Trimester Second Trimester ThirdTrimester
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  FIRST TRIMESTER
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  Screening is VOLUNTARY Screeningshould be made UNIVERSAL  SCREENING SHOULD BE OFFERED TO EVERYONE  Screening should be DONE only to women willing for the same  Those who decline screening may not be offered this tests and decision should be documented.
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  FIRST TRIMESTER
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  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
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  General Examination • Heart– Murmurs • Lungs – Rhonchi • Breast – Lumps / Nipples • Abdomen – Scars / Lumps • Per Speculum – Discharge / Polyp / Erosion LBC / HPV • Anus – Sentinel Pile
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  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
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  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
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  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
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  Endocrine Screening • Thyroidfunction test • If abnormal, thyroid antibodies • In PCO – screen for GDM early (HbA1C) • If galactorrhea – Prolactin • Serum Vitamin D • Relaxin ?
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  Infection Screen • Completeblood 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
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  Biochemical Screening
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  Watch carefully the picture
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  Where do allthese markers come from? (adrenals) (liver)
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  Various Integrated screeningin strategies (1st and 2nd trim) Main strategies: • Fully Integrated • Step-wise sequential • Contingent screening 1st trimester: NT, PAPP-A No risk estimate 2nd trimester: Fb-hCG, AFP, uE3, (± Inhibin) Final risk estimate: All markers 1st trimester: NT, PAPP-A, Fb-hCG Risk estimate 2nd trimester: Fb-hCG, AFP, uE3, (± Inhibin) Final risk estimate: All markers CVS NIPT High risk Low risk 1st trimester: NT, PAPP-A, Fb-hCG Risk estimate 2nd trimester: Fb-hCG, AFP, uE3, (± Inhibin) Final risk estimate: All markers CVS NIPT HR Borderline risk No further screening LR
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  First trimester screeningfor Preeclampsia Maternal serum PIGF, Mean arterial Blood pressure - Implantation - Maternal artery remodelling Detection rate – 90% 0 10 20 30 Falsepositive(%) Doppler 12% 30% PP13 9% Doppler & PP13
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  New Screening Protocolfor Trisomy 21 + PE + ONTDs in Indian Scenario Viability Scan: 6-8 weeks LOW RISK HIGH RISK NIPT Anomaly scan at 19 weeks with genetic sonogram Amniocentesis CVS LOW RISKHIGH RISKLOW RISK HIGH RISK
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  Non Invasive PrenatalTesting (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
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  CVS •11-14 weeks •Transcervical •Check forchorionic villi under microscope •Risk of miscarriage 1% •Need is obviated now due to NIPT
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  Amniocentesis •15-18 weeks •Risk ofmiscarriage < 1% •To confirm diagnosis in positive integrated screen and/or positive NIPT •To screen known carriers for chromosomally abnormal fetus
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  FIRST TRIMESTER SCREENING FOR CHROMOSOMAL ANOMALIES
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  Screening in the1st trimester • Time window: 8 - 14 weeks • Ultrasound Marker: • NT • Biochemical markers: • PAPP-A • Fb-hCG • Marker combination: • Combined test: NT, PAPP-A, Fb hCG
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  Screening for Trisomy21 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
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  Screening for Trisomy21 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
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  • MA +NIPT(OPTIONAL) • Dual Marker • NT + NB + TR + DV First trimester • Quad Marker • Genetic Sonogram Second trimester Integrated 1st and 2nd trimester screening DR – 97% FPR – 2.5%
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  SO PROPOSAL ISINDIAN CONTINGENT SCREEN OR INTEGRATED FIRST AND SECOND TRIMESTER SCREEN COMBINED FIRST TRIMESTER SCREEN FOR RISK ESTIMATE……. FOLLOWED BY COMBINED 2ND TRIMESTER RISK SCREENING
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  99
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  COMBINED SCREENING &RISK ESTIMATION IN FIRST TRIMESTER 100099
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  1LOW LEVELS PREDICTPRE 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
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  Greater opportunity tosecure a healthy pregnancy and healthy child, with 1st Trimester evaluation WHY CHOOSE BE HAPPY FIRST TRIMESTER PREGNANCY CHECK?  All the advantages of 1T screening: Earlier reassurance and early intervention if required  Enhanced performance for 1T combined aneuploidy screening: To enable to higher DR or lower FPR  4 marker biochemistry: Aneuploidy risk on par with 2T Quad  Some significant Fetal structural abnormalities  Pre-term Pre-eclampsia: Identify a high risk group, who would benefit from Aspirin
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  First Trimester Second Trimester ThirdTrimester
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  SECOND TRIMESTER SCREENING
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  CERVICAL LENGTH SCREENING ROUTINETO PREVENT PRETERM LABOUR AND FOR GUIDELINE FOR CX STITCH • ASYMPTOMATIC SINGLETON PREGNANCY A TVS CL <25 MM IN SECOND TRIMESTER • SCREEN AT 11-13 WEEKS AND 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
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  SECOND TRIMESTER
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  Second Trimester RecommendedPreferable 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
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  Sequential Screening •Quadruple marker– 15-18 weeks •NIPT 9 week onwards •Amniocentesis – 15 week onwards
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  COMBINED 2ND TRIMESTERSCREENING
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  ANOMALY SCAN
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  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
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  Screening for PIH •Blood Pressure BOTH ARMS SITTING • 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
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  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
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  First Trimester Second Trimester ThirdTrimester
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  THIRD TRIMESTER SCREEN
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  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 PAPP A- 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 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 (6 in 2 hours) CTG (NST) Modified biophysical Score Doppler velocimetry
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  THIRD TRIMESTER
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  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
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  NON USG SCREENING FORFETAL WELL BEING
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  CARDIOTOCOGRAPHY
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  Cardiotocography • Non Stresstest 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
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  KICK CHART
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  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
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  About baby’s movements Anactive 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.
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  TWEAK Screening foralcoholism • 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
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  • Antepartum fetalsurveillance 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
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  FETUS AT RISK •PRE TERM • POST TERM • IUGR • THICK MECONIUM WITH SCANTY FLUID • INTRAUTERINE INFECTION • INTRAPARTUM BLEEDING 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 FETUS AT RELATIVE RISK
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  Admission assessment Are anyrisk 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
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  INDICATION OF FETALSURVEILLANCE •Maternal conditions • Hypertension • Diabetes mellitus • Heart Disease • Chronic renal disease • Acute febrile illness • Pneumonia /asthma • Epilepsy
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  • Collagen vasculardisease • Sickle cell disease • Antiphospholipid syndrome • Drug Abuse • FETAL CONDITIONS • Fetal growth restriction • Rh isoimmunisation • Fetal Cardiac arrythmia
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  • Hydrops fetalis •Fetal infections • PREGNANCY RELATED CONDITIONS • Preeclampsia • Multiple pregnancy • Post term pregnancy • Decreased fetal movements • Abnormal placentation • Placental abruption
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  • Oligohydramnios • Polyhydramnios •Unexplained stillbirth in a previous pregnancy • Cholestasis of pregnancy • PROM • Poorly controlled Gestational Diabetes mellitus
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  The Various Methodsof 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
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  Check list madea few years back…….NOW TO BE MODIFIED
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  SCREENING IN PREGNANCY Atbooking (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)
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  1LOW LEVELS PREDICTPRE 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
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  Second Trimester RecommendedPreferable 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
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  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 PAPP A- 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 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 (6 in 2 hours) CTG (NST) Modified biophysical Score Doppler velocimetry
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  FIRST TRIMESTER
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  COMBINED SCREENING &RISK ESTIMATION IN FIRST TRIMESTER
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  SECOND TRIMESTER
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  COMBINED 2ND TRIMESTERSCREENING
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  THIRD TRIMESTER
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  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 PAPP A- 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 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 (6 in 2 hours) CTG (NST) Modified biophysical Score Doppler velocimetry
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  Preconception advises andscreening • BMI • BP • SCREEN FOR INFECTIONS (RUBELLA) • BLOOD GLUCOSE • PCO AND OTHER ENDORINE :TSH/ PRL • ROUTINE BLOOD TESTS • THALLASIMEA SCREEN
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  PRECONCEPTION ADVICES • LIFESTYLE •GARBH SANSKAR SPIRITUAL • DIET • EXERCISE/YOGA/MEDITATION • FOLIC ACID SUPPLIMENTATION • ANEMIA CORRECTION IF DETECTED • CORRECTION OF ENDOCRINE FACTORS • VACCINATE FOR RUBELLA/HPV AND OTHERS
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  Why vaccinate women??? • Vaccination before during and after pregnancy helps protect women from serious infections . • It can also help in improving the women’s health in general . • It is an important preventable measure which should be adopted rationally
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  • Ideally, allwomen should be up-to-date with their vaccinations before they become pregnant. • It is known that approximately 50 percent of all pregnancies are unplanned • it is important to keep women of reproductive age current with immunizations, regardless of whether they are actively trying to conceive.
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  Adolescent vaccination recommendations MMR(2),Hep B ,Hep A ,HPV, tetanus,diphtheria , influenza and VAR(2) catch up vaccination is recommended from 11 years onwards. Typhoid and cholera vaccination can be given seasonally.
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  VACCINES OF THETEENAGE GIRL • Catch up vaccinations for Hepatitis B, Tetanus, diphtheria acellular pertussis(Tdap),typhoid, Influenza, rubella and HPV are recommended in the adolescent age group. • The medical history of prior affliction with these diseases should be elicited. • Previous adverse effects of immunizations especially allergies should be noted.
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  PRECONCEPTION COUNSELING /PREGNANCY PLANNING