There are no standardized guidelines/protocols for conducting common laboratory investigations during pregnancy. Here is an attempt to educate Pregnant ladies in this important aspect of their healthcare.

1. COMMON LAB. INVESTIGATIONS
IN PREGNANCY
With specific reference to Anaemia, Leukocytosis,
Thrombocytopenia, GDM.
Dr. NISHEETH M. OZA

2. Dr. Nisheeth M. Oza
M.D., D.G.O., F.C.P.S., D.N.B., (M.N.A.M.S.) (OBGYN)
D.A., M.B.B.S., Dip. YAN
Obstetrician, Gynaecologist, Infertility Consultant,
FMF Certified Ultrasonographer (FMF ID 145907)
Licensed for Aneuploidy Screening NT, NB, DV, Cervix & PIH Screening.
Diploma in Yoga, Ayurveda & Naturopathy
Dr. Oza’s Hospital 87/7, Panvel 410206, Maharashtra India.
Email : drnmozas@gmail.com
Website : drozashospital.com
YouTube : DrOzaConnects

3. INTRODUCTION
When a Lady visits her Doctor during her pregnancy, she may be asked to undergo
certain Laboratory Investigations at several times, e.g.
In her first visit,
At 11-14 weeks,
At 26-28 weeks,
At 34-36 weeks,
She may wonder as to
Whether the Lab. Investigations are necessary?
WHICH? WHEN? WHY?

4. AIM OF LAB. INVESTIGATIONS – WHY?
• As a part of Prenatal (Antenatal) Care.
• To ascertain the well being of P.W. eg Her Haemoglobin test.
• To find out the conditions that may increase the risk of complications eg GDM
(BS/DIPSI Test), UTI (Urine C/S), Hypothyroidism (S. TSH).
• To find out conditions that may need special care & management eg Rh Negative,
Haemoglobinopathy or STI.
• To find out the conditions that may modify the management of P.W. & her N.B. eg
HIV positive.

5. WHEN?
• FIRST TRIMESTER/FIRST VISIT :
Antenatal Profile – Antenatal Panel.
May combine it with Genetic Screening Tests at 11-24 weeks.
• SECOND TRIMESTER 24-48 WEEKS :
GDM, UTI, Anaemia.
• THIRD TRIMESTER 35-37 WEEKS :
GBS (Group B Streptococcal Vaginal Culture).
UTI, Anaemia, Pre-eclampsia.

6. FIRST TRIMESTER/FIRST VISIT LAB. TESTS
MOST IMPORTANT: HbA1C, S. TSH.
MINIMUM : CBC, Bl. Group & Rh type, HbA1C/DIPSI Test, S.TSH. Urine-R/M including
Dipstick (Protein, Sugar, Pus cells, Nitrite).
PREFERABLE : HIV, HBsAg, HCV, VDRL.
BT, CT, PT.
Urine C/S.
OFFERED : Hb Electrophoresis – Abnormal Hb Study (Hb HPLC).
Rapid Malaria Test (kit), Thick & Thin Smear.
PAP Smear (Cytology).
Rubella IgG.
FUTURE : COVID-19 IgG, IgM.
Note: These may be combined with Genetic Screening Tests recommended between 11and 14 weeks, If
not performed prior to that.

7. SECOND TRIMESTER: 24-28 WEEKS
• CBC
• DIPSI TEST, SOS OGTT
• Urine Dipstick (Protein, Sugar, Pus Cells, Nitrate)
THIRD TRIMESTER: 35-37 WEEKS
• CBC
• Urine Dipstick (Protein, Sugar, Pus Cells, Nitrate)
• SOS Serum Creatinine, Serum Uric Acid
• Group B Streptococcal Vaginal Culture (GBS)
• Before Delivery : As per prevailing Protocol : COVID-19 rt PCR.

8. WHICH TESTS ? WHAT IS THE SIGNIFICANCE?
A] CBC
COMPONENT CRITICAL VALUE FUNCTIONS
Hb < 8 grams% Carrying Oxygen to Tissues.
WBC > 15,000/cu mm Fighting against Germs.
Platelet Count < 1,00,000/ cu mm Facilitate Blood Clotting.
Mentzer Index < 13 Indicates Possibility of
Haemoglobinopathy.

9. LOW HB LEVEL: ANAEMIA IN PREGNANCY
FUNCTION OF Hb : Carrying Oxygen to Tissues of P.W. & her fetus.
PHYSIOLOGICAL : Plasma Volume(Liq. Component), more (50%) then RBC Vol.
CHANGES (Solid Component) (30%), thereby Haemodilution, Hb by around 1 to 2 gm/dl.
DEFINITION (WHO) : Hb < 11 grams/dl.
INCIDENCE : Affects > 40% P.W. world wide.
DETERMINE : Severity : Mild: Hb 10-10.9 gm/dl, Mod: 7.0-9.9 gm/dl,
Severe: 4-6.9 gm/dl, Very Severe Hb < 4 gm/dl.
Type e.g. Microcytic Hypochromic.
Causes e.g. Iron-Deficiency.

10. SINGNIFICANCE :
1) Severe Anaemia contributes to and increases risk of death in P.W. (Maternal
Mortality).
2) Increases ill Health (Morbidity) e.g. Increases Susceptibility to Infections,
Increases need for Blood Transfusion, Increases risk of Postpartum Depression.
3) Increases Obstetric Complications e.g. Pre-eclampsia, Abruptio-Placentae,
Preterm Birth, LBW babies.
4) Increases Adverse Fetal Outcome – FGR, PNMR.
5) Newborn: Increased NMR, Abnormal Auditory Maturation.
6) Child : Impaired Psychomotor & Mental Development, Increased Cognitive &
behavioral abnormalities.

11. TREATMENT : IRON DEFICIENCY ANAEMIA
DIET : Green Leafy Vegetables, Jaggery.
DEWORMING : Albendazole, Mebendazole, after 13 weeks.
TREATMENT :
ORAL IRON : Elemental Iron 100-200 mg/day.
Problems : Tolerance, Compliance, GI side effects.
Supportive treatment: For side effects like Constipation.
PARENTERAL IRON: I.V. Iron Sucrose.
I.V. Ferric Carboxymaltose.
BLOOD TRANSFUSION : Rarely required eg. If Hb < 6 grams% & patient is in Third
Trimester of Pregnancy.

12. INCREASE IN WBC COUNT : LEUKOCYTOSIS IN PREGNANCY
FUNCTIONS OF WBC : Fighting against Germs (micro-organisms).
PHYSIOLOGICAL : Total WBC (White Blood Cell) Count increases in pregnancy, particularly the
Neutrophils, to help her fight against germs.
Especially when she is nearing EDD, during Labour & during puerperium.
WBC count upto 15,000/cumm is normal, especially Near Term During Labour,
WBC count 25,000/cumm is normal.
PATHOLOGICAL : Severe Pre-eclampsia.
CAUSES Stress, Intense Exercise, Trauma, Surgery.
Antenatal Infections : Cold, UTI, Eye Infections.
Infection During Labour or During Puerperium, Autoimmune disease like
Rheumatoid Arthritis, SLE.
TREATMENT : According to the cause, e.g. UTI-Urine C/S – Appropriate Antibiotics
Supportive care – Paracetamol for fever , personal Hygeine, Improving Immunity.

13. DECREASE IN PLATELET COUNT : THROMBOCYTOPENIA IN PREGNANCY
FUNCTION OF PLATELET : Help in and facilitating Blood Clotting Process.
PHYSIOLOGICAL : Platelet Count decreases in 10% pf P.W. especially between 30 & 40 weeks
to level below 1,50,000/cumm.
CHARACTERISTICS : No H/o low Platelet Count before conceiving, count is >70,000/cumm, No
H/o Bleeding, Count returns to normal within 12 weeks after delivery.
CRITICAL VALUE in Pregnancy is <1,00,000/cumm.
PATHOLOGICAL : Malaria, Dengue.
Pre-eclampsia, HELLP Syndrome (21%).
Immune Thrombocytopenia (ITP) 4%.
Less common: SLE,ALPA,TTP-HUS, Acute Fatty Liver of Pregnancy, DIC, HIV
infection, Hypersplenism & Medications.
TREATMENT : According to the cause.

14. ABO BLOOD GROUP & Rh TYPE
BLOOD GROUPS : A, B, AB, O.
Rh TYPES : Rh Positive, Rh Negative.
SIGNIFICANCE : In some complications during pregnancy, Labour or Puerperium, P.W. may require
Blood Transfusion.
If Pregnant women is Rh-Negative, Certain additional investigations & treatment
are required.

15. Inj. Anti D 300 mcg at 28 weeks Monitor P.W. with Col.Doppler MCA-PSA
After Delivery
Newborn’s Blood group IUT SOS, Timely Delivery.
No Further Action Adm. Inj Anti D 300 mcg to P.Mother within 72 hours
Watch for NB Jaundice -> Management-Phototherapy
P.W IS Rh Negative
Test her Husband-Blood group & Rh Type
Husband Rh Negative
No Further Test/Action
Husband Rh Positive
W:Anti Rh Ab – Early pr. & 28 weeks
Negative Positive
Rh Negative Rh Positive

16. HbA1C, BS-F & PP, DIPSI TEST , OGTT
AIM : To detect GDM-Gestational Diabetes Mellitus & Manage it.
To differentiate between PGDM-Pregestational Diabetes Mellitus & GDM if not
previously known to be Diabetic(PGDM); with the help of HbA1C in 1st Trimester.
To Identify women at the greatest risk for Congenital Malformations of fetus :from
HbA1C levels in 1st Trimester.
INCIDENCE : GDM 90% & PGDM 10% of all cases of Diabetes Mellitus in Pregnancy.
GDM in India 4 to 21 %
30% of GDM patients do not have risk factor, hence Universal screening is
recommended.

17. MALFORMATION RISK : Haemoglobin A1c Major Malformation
< 6% 2-3%
6-7 % 5-10%
8-10 % 10-25%
>10% >25%
METHODS :
HbA1C (GLYCOSYLATED HAEMOGLOBIN)
It represents glycaemic control (sugar level) in previous three months.
Hence it can differentiate GDM from PGDM if performed in 1st Trimester.
HbA1C > 6.5% in 1st Trimester – implies PGDM
Target : In each Trimester 6% or less.
BS (BLOODSUGAR) FASTING & PP (POST PRANDIAL)
Venous blood Sugar In 1st trim PGDM
Fasting : >126 mg/dl
Post Prandial : >200 mg/dl
Target: Fasting BS < 100 mg/dl.
2 hours Post Lunch <120 mg/dl.

18. DIPSI TEST
DIABETES IN PREGNANCY STUDY GROUP OF INDIA TEST
It is simple ,less cumbersome, cost effective, easily acceptable, efficient screening test, may be performed in
each trimester.
WHEN? : At first antenatal visit, then repeat between 24and 28 weeks.
HOW? : No need of fasting status.
75 gram of glucose mixed with 300 ml of water , is consumed by PW, slowly over 5 to 10 minutes,
after two hours test the blood glucose level. .
NORMAL : Blood glucose < 140 mg/dl.
CRITICAL : Blood glucose > 140 mg/dl – GDM 15% require OGTT to confirm diagnosis
: Blood glucose > 200 mg/dl – Diagnostic for GDM [ OGTT not needed]
NOTE It the vomits within 30 minutes after drinking, conduct the test on another day .
If PW vomits after 30 minutes of consumption, go on with the test.

19. OGTT
ORAL GLUCOSE TOLERANCE TEST
WHEN? : For definitive diagnosis of GDM.
If Random BS or DIPSI Test is 140-150 mg/dl.
At 28 weeks of pregnancy if first Trimester Screening was negative.
HOW? : 75 grams glucose challenge.
Fasting overnight for at least 8 hours (not > 14 hours).
CRITICAL VALUES : Venous glucose Concentration for diagnosis of DM
NDDG(mg/dl) Carpenter & Counstan(mg/dl)
Fasting 105 95
1-hour 190 180
2-hour 165 155
3-hour 145 140
--------------------------------------------------------------------------------------------------------------------------------------------------------
NDDG : National Diabetes Data Group
Carpenter & Coustan. Am J Ob Gyn 1982

20. WHY BOTHER TO SCREEN FOR GDM? CONSEQUENCES
I MATERNAL:
• Increased risk for Pre-eclampsia, Caesarean Delivery.
• 60% of GDM may develop over type 2 Diabetes Mellitus within 16 years, and may have shortened
life expectancy due to Cardiovascular disease.
II FETAL AND NEONATAL:
• Excessive fetal growth and birth trauma, including Shoulder Dystocia, Neonatal Hypoglycaemia,
Hypocalcaemia, Hyperbilirubinemia.
• Increased Perinatal Mortality associated with significant Maternal Hyperglycemia (uncontrolled) :
Class A2 Diabetes i.e. requiring Diet, Exercise & Insulin or Metformin.

21. ANTEPARTUM MANAGEMENT OF GDM
VISIT : 1-2 weeks until 36 weeks, then weekly.
DIET : 3 meals, bedtime snack.
2000-2200 Kcal/day.
Carbo 40-50% Protein 20%, Fat 30-40%, High fibre.
WEIGHT GAIN : Depending on BMI.
EXERCISE : Regular Exercise, 30 minutes moderate exercise (brisk walking).
SURVEILLANCE : SMBG- Self Monitoring of Capillary Blood Glucose.
If Fasting >95 mg/dl, 1 hour >140 mg/dl &/or 2 hour>120 mg/dl, Acid Insulin
(preferable) or Metformin.
INSULIN : 1st Trimester 0.8 u/kg 2nd Trimester 1.0 u/kg 3rd Trimester 1.2 u/kg.
50% as Basal Insulin (NPH)- 2/3rd fasting 1/3rd bedtime.
50% as Prandial Insulin (Insulin Lispro or As part).

22. METFORMIN : If patient refuses Insulin or If cost is the problem. 500 mg with dinner increases upto
1000 mg twice a day.
Side Effects : 10-25% transient GI side effects. 40% may need supplemental Insulin.
Does cross placenta, but no adverse Fetal/Neonatal/Child effects.
DELIVERY : Well controlled on Diet & Exercise ; 39-40 weeks.
suboptimally controlled – before 39 weeks.
PIH or Prior SB or class A2 NST twice a week from 32 weeks.
SFH & USG – W/F excessive fetal growth.
Wt > 4500 gm – LSCS
Wt 4000-4500 gm, consider prior obstetric history, pelvic capacity Alert Neonatal
Team- Hypoglycaemia, Hypocalacemia, Hyperbilirubinaemia.
Encourage breast feeding.

23. POST PARTUM CARE
SMBG 24-72 hours after delivery.
4-12 weeks fasting glucose or 75 gm oral GTT.
VALUES FOR VENOUS PLASMA GLUCOSE (mg/dl)
Time Normal Prediabetes Diabetes Mellitus
Fasting <100 100-125 >126
2 hrs after 75 gm <140 140-199 > 200
If normal, evaluate annually Fasting or HbA1C and every 1-3 years with 75 gm OGTT.
Encourage exercise & if obese, weight loss.
OCs : Low dose pills-No Carbohydrate intolerance.
RECURRENCE RISK IN SUBSEQUENT PREGNANCIES 40-60%
Testing for GDM in subsequent pregnancies.

24. THANK YOU