Maternal screening in pregnancy final

MATERNAL SCREENING
IN PREGNANCY
Dr.Narendra Malhotra
Dr. Mala Arora
(Dr Ranjana Khanna,Dr Abha Rani Sinha,
Dr Pragya Mishra,Dr.navneet Magon,Dr Ganpat Sawant}
30-05-2017 TOG Conclave 1
FOGSI-TOG Conclave GOA Jun 2017

PROF.NARENDRA MALHOTRA
M.D.,F.I.C.O.G.,F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.,F.M.A.S.,F.I.A.P
• Prof. Dubrovnick International University
• V.P. WAPM(world association of prenatal medicinne)
• President ISAR
• Presiddent Elect ISPAT
• Sec Gen SAFOG
• Member FIGO guidelines committee
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Managing Director GLOBAL RAINBOW HEALTH CARE
• Director ART-RAINBOW –IVF
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
• Over 50 published and 200 presented papers
• Over 100 guest lectures given in India & Abroad and 24 ORATIONS
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 18 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology 7th and 8th edition (2015)
• Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA
84, M.G. Road, Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194

Dr. Mala Arora
FRCOG (UK), FICOG,FICMCH
CHAIRPERSON ICOG 2017
VICE PRESIDENT FOGSI 2011
Chief Editor Recurrent Pregnancy Loss 2003,2007
World Clinics in Obst & Gynae Vol 1-9
First Trimester of Pregnancy
Hyperhomocystenemia in Ob / Gynae
Associate Editor Clinical Essays for MRCOG Part 2
Associate Editor International Journal of IFM
Peer Reviewer JHRS & Saudi Medical Journal
CPD Accreditation from RCOG (UK)

EXPERT GROUP
MODERATORS
DR NARENDRA MALHOTRA
DR MALA ARORA
PANELISTS
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 ?

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

PREVENT MATERNAL
COMPLICATIONS
First Trimester Screening

ADD SCREENING FOR N.C.D.HERE
THE PYRAMID OF ANTENATAL CARE

Routine Antenatal Care 1990s…….
Early scan to
diagnose
pregnancy &
dating
Fetal defects
22-24 wks
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 TO BE MODIFIED BY THIS MEETING

First Trimester
Second Trimester
Third Trimester

FIRST 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

Serum Integrated Screening SIPS
• Double marker test – free BHCG + PAPP A
(CRL >45 mm , live fetus, scan dating + NT)
• Quadruple Screening – Triple Marker –
Maternal Serum Screening
(estriol + free beta HCG + alpha fetoprotein
+ PAPP A+ Inhibin A)
• NT screening to be added 11-13+4 weeks

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

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

Maternal Serum Markers
• First Trimester: Papp-A
Free beta hcG
• Second Trimester: AFP
uE3
hCG
Inhibin-A

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

First trimester screening for
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

FIRST TRIMESTER
SCREENING

Various Integrated screening in
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:
All markers
CVS
NIPT
High risk
Low risk
1st trimester:
NT, PAPP-A, Fb-hCG
Risk estimate
2nd trimester:
All markers
CVS
NIPT
HR
Borderline risk
No further
screening
LR

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

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

• 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%

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
NIPT
Placental Growth Factor
(PLGF)
Per speculum exam Pap Smear, Bacterial vaginosis &
Chlamydia screen

First Trimester
Second Trimester
Third Trimester

SECOND TRIMESTER
SCREENING

CERVICAL LENGTH SCREENING
ROUTINE TO 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

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

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

COMBINED 2ND TRIMESTER SCREENING

ANOMALY SCAN

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 – two doses
• Influenza vaccine
• Targetted Vaccine in case of travel to
endemic areas
• Post partum – HPV vaccine

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

First Trimester
Second Trimester
Third Trimester

THIRD TRIMESTER
SCREEN

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

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

KICK CHART

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
INJUDICIOUS USE OF
OXYTOCIN
EPIDURAL IN A CASE
WITH SOME
COMPROMISE
DIFFICULT
INSTRUMENTAL
DELIVERY/
MACROSOMIA/
MALPRESENTATION
ACUTE EVENTS (CORD
PROLAPSE, ABRUPTION,
SCAR RUPTURE)
FETUS AT
RELATIVE RISK

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

WE PROPOSE AT THIS
CONCLAVE
THE FOLLOWING TESTS TO BE
RECOMMENDED AND PREFERABLE
THE WORDS MANDATORY IS DELEBERATELY
AVOIDED TO PREVENT MEDICOLEGAL
ISSUES

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)

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
NIPT
Placental Growth Factor
(PLGF)
Per speculum exam Pap Smear, Bacterial vaginosis &
Chlamydia screen

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

Thank you

Maternal screening in pregnancy final

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