Prenatal Care

Screening and Testing Guideline

Visit Schedule Initial Visit Second Trimester Visits (1428 Weeks) Third Trimester Visits (2841 Weeks) Postpartum Care Visit References Clinician Lead and Guideline Development

2 2 6 7 8 9 10

Most recent evidence review: June 2012

Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. While guidelines are useful aids to assist providers in determining appropriate practices for many patients with specific clinical problems or prevention issues, guidelines are not meant to replace the clinical judgment of the individual provider or establish a standard of care. The recommendations contained in the guidelines may not be appropriate for use in all circumstances. The inclusion of a recommendation in a guideline does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient.

Prenatal Care Screening and Testing Guideline Copyright 20032012 Group Health Cooperative. All rights reserved.

Visit Schedule

Initial visit Early second trimester (1416 weeks) Late second trimester (2428 weeks) Third trimester (32 weeks, 36 weeks, 38 weeks, 39 weeks, 40 weeks, 41 weeks) Postpartum care (46 weeks post-delivery)

Initial Visit
History
Initiate transfer of the patients outside medical records from prior births involving cesarean delivery and/or complicated pregnancies. Update the patients history in the medical record to include all active problems and medical/surgical history, including prior cesarean or chronic hypertension.

Current pregnancy history Past obstetric history Menstrual history Sexual history Contraceptive history Medical and surgical history Infection history Genetics history Immunization status Medications and allergies

Exposure to teratogens Sociodemographic data Pregnancy readiness Nutrition Housing/finances Social support HIV/STI risk Tobacco use history Alcohol history Drug use history

Consider using a tool to review important medical/surgery history, such as: Group Health Family History and Pregnancy Questionnaire (within Group Health): http://incontext.ghc.org/womens_health/documents/GHhistory.pdf The U.S. Surgeon Generals My Family Health Portrait Tool: http://www.hhs.gov/familyhistory/

Behavior, lifestyle and social issues

If patient: Smokes, advise to quit and refer to Quit for Life or other tobacco cessation program. Is an at-risk drinker or uses drugs, refer to social worker. Has HIV/STI risk, perform risk-reduction counseling. Discloses intimate partner violence, complete safety assessment and supply information regarding support services. Connect patients to resources for family assistance and information. Offer information about nonprofit statewide programs in Washington state: Within Reach: http://withinreachwa.org/ ParentHelp123: www.parenthelp123.org

Physical examination
Lactation assessment should be included in the physical exam.

Logistical issues
If the designated birthing facility has a weight limit and the patient is above that maximum weight, initiate discussion regarding an alternative delivery location.

Prenatal Care Screening and Testing Guideline

Screening and testing

Table 1. Initial prenatal visit: screening and testing Test

Eligible population All pregnant women.

Blood type and Rh Antibody screen CBC HbA1c 1 Depression, PHQ-9 2 Alcohol use, AUDIT 3 HIV, with patient counseling Syphilis, RPR Chlamydia testing Hepatitis B surface antigen Rubella immunity Varicella immunity Urine testing followed by urine culture for positive results

Toxoplasmosis screening

Women with risk factors for toxoplasmosis, such as high risk of exposure to contaminated undercooked meat, untreated drinking water, or cat litter boxes. Women with risk factors for sexually transmitted infections (STI) such as less than 25, multiple sexual partners, history or prior STI. Women with risk factors for STI and women who are immunocompromised. Women with risk factors for TB, such as poverty, drug use, HIV, and immigrants from TB endemic areas. Women with risk factors for CMV, such as day care workers, NICU nurses, and adolescents with multiple sexual partners or a history of STI. Women with a history of injection drug use or a history of blood transfusion or organ transplantation prior to 1992. Women older than 21 without a current Pap test. Women with hypothyroidism. Women in whom there is clinical suspicion of drug abuse.

Gonorrhea testing

Herpes simplex virus (HSV) Tuberculosis (TB) screening Cytomegalovirus (CMV)

Hepatitis C antibody testing Pap test Thyroid-stimulating hormone (TSH) testing 4 Drug abuse screening, DAST-10 5
1

2 3 4

If HbA1c is negative but diabetes is suspected due to symptoms, BMI, or ultrasound findings, a provocative test is recommended (2-hour oral glucose tolerance test with 75 g glucose load). See the Group Health Gestational Diabetes Guideline. See the Group Health Adult Depression Guideline. See the Group Health Adult Alcohol Misuse and Withdrawal Guideline. TSH reference range for pregnant patients: First trimester (014 weeks) 0.032.5 mIU/L Second trimester (1528 weeks) 0.033.0 mIU/L Third trimester (2840 weeks) 0.133.0 mIU/L See the Group Health Adult Drug Misuse and Withdrawal Guideline.

Prenatal Care Screening and Testing Guideline

Immunizations
Table 2. Immunizations for pregnant women and their families 1 Vaccine Preservative-free influenza vaccine Hepatitis B vaccine Eligible population All pregnant women. Patient has: More than one sex partner during the previous 6 months. Previous evaluation or treatment for a sexually transmitted disease. Recent or current injection drug use. HBsAg-positive sex partner. Pregnant women who have never been vaccinated. Patients family members and potential caregivers for newborns.

Tdap 2 Tdap and flu immunization before the patient gives birth
1 2

CDC Guidelines for Vaccinating Pregnant Women: www.cdc.gov/vaccines/pubs/preg-guide.htm To ensure protection against maternal and neonatal tetanus, pregnant women who have never been vaccinated against tetanus should receive three vaccinations containing tetanus and reduced diphtheria toxoids. The recommended schedule is 0, 4 weeks, and 612 months. Tdap should replace one dose of Td, preferably during the third or late second trimester (after 20 weeks gestation) of pregnancy. (CDC 2012).

The following vaccines are contraindicated during pregnancy: HPV Influenza in live attenuated influenza vaccine (LAIV) form; patients should receive inactive form. MMR or its component vaccines (measles, mumps, rubella) Varicella BCG (LAV)

Screening for genetic risk

Provide information about options for testing to measure the risk of having a baby with genetic birth defects. Carrier status testing should be offered for certain high-risk populations (see Table 3), and chromosomal abnormality screening should be offered to all (see Table 4). Table 3. First trimester screening for inherited disorders Condition
Sickle cell Thalassemia

When Initial prenatal visit

Test
Hemoglobin

Eligible population 1 Asian, Mediterranean descent, African American Ashkenazi Jewish descent

electrophoresis
Ashkenazi panel

Cystic fibrosis Initial prenatal visit Tay-Sachs Canavan's disease Familial dysautonomia
2

Cystic fibrosis
1 2

Initial prenatal visit

Cystic fibrosis

All pregnant women

carrier testing Some women might elect not to do genetic screening. See Clinical Review Criteria for Genetic Screening and Testing at www.ghc.org/all-sites/clinical/criteria/pdf/genetic_screening.pdf.

Prenatal Care Screening and Testing Guideline

Both the integrated and the prenatal risk quad screen (PRS) are reasonable options to estimate patientspecific risk for chromosomal abnormalities. While the integrated screen has a higher detection rate (95% vs. 81%) and lower false positive rate (1% vs. 7%) than the PRS (Malone 2005), other factors such as timing, maternal preference, and availability may favor the PRS screen. Whichever screening test is used, the patient should be advised that the screening provides an individual risk assessment, but it is not diagnostic. A positive screening test must be followed by an invasive diagnostic test (chorionic villus sampling or amniocentesis) in order to definitively diagnose chromosomal abnormalities. Table 4. First and second trimester genetic evaluation for chromosomal abnormalities Condition When Test Eligible population 1

Integrated screen Integrated screen uses markers measured in both first and second trimesters together with maternal age to estimate patient specific risk.
Down syndrome Trisomy 18 Neural tube

1114 weeks

Nuchal translucency

All pregnant women

defects and 1522 weeks

screening (NTS) ultrasound PAPP-A

Alpha-fetoprotein

(AFP)
Unconjugated estriol

(UE)
Human chorionic

gonadotropin (hCG)
Inhibin-A

Prenatal risk quad screen (PRS) This screen uses markers measured in the second trimester together with maternal age to estimate patient specific risk.
Down syndrome Trisomy 18 Neural tube

1522 weeks

Alpha-fetoprotein

All pregnant women

defects

(AFP) Unconjugated estriol (UE) Human chorionic gonadotropin (hCG) Inhibin-A

Invasive diagnostic testing Both tests may be used to definitively diagnosis aneuploidy. The choice of test is based on timing, maternal preference, and the need for further neural tube defect testing.
Chromosome

1013 weeks

problems Inherited disorders

Chromosome

Chorionic villus sampling Women at increased risk for genetic (CVS) birth defects due to advanced maternal age, family history, or abnormal first trimester screening Amniocentesis Women at increased risk for genetic birth defects due to advanced maternal age, family history, or abnormal first trimester screening

1522 weeks

problems Inherited disorders Neural tube defects

1

Some women might elect not to do genetic screening.

Prenatal Care Screening and Testing Guideline

Second Trimester Visits (1428 Weeks)

Physical examination (1416 weeks)
Weight Blood pressure Auscultation of fetal heart tones

Physical examination (2428 weeks)

Weight Blood pressure Auscultation of fetal heart tones Measurement of fundal height

Screening and testing

Ultrasound screening (1822 weeks) See Table 4 (previous page) for information on chromosomal abnormality screening during the

second trimester. Table 5. Late second trimester (2428 weeks): screening and testing Test
Hematocrit 2-hour glucose tolerance test
1,2

Eligible population All pregnant women Women with risk factors for gestational hypertension, such as first pregnancy or high blood pressure or kidney disease prior to pregnancy

PIH (pregnancy-induced hypertension)

urine protein
1 2

Refer to dietitian if abnormal values on 2-hour glucose tolerance test. Instruct in glucose monitoring if abnormal values on 2-hour glucose tolerance test.

Prenatal Care Screening and Testing Guideline

Third Trimester Visits (2841 Weeks)

Physical examination

Weight Blood pressure Auscultation of fetal heart tones Measurement of fundal height Determination of fetal lie at 36 weeks and subsequent visits Cervical examination by 42 weeks

Interventions
If fetus is breech at 36 weeks, offer external cephalic version.

Screening and testing

Table 6. Third trimester (2841 weeks): screening and testing Test
Group B strep vaginal and rectal culture at

Eligible population All pregnant women.

3537 weeks Non-stress test (or alternative test for fetal well-being) by 42 weeks 1 1,2 Antibody screen

Chlamydia Gonorrhea testing Syphilis, RPR HIV Herpes Hepatitis B surface antigen
1

Women at high risk for STI.

MRSA screening at 3438 weeks

1

Women with a history of MRSA colonization.

Policies and procedures regarding non-stress testing, RhoGAM administration, and MRSA screening are similar at the following facilities where Group Health staff obstetricians see patients: Overlake Hospital (Bellevue), Providence General Medical Center (Everett), Harrison Memorial Hospital (Bremerton), St. Joseph Hospital (Bellingham), Providence St. Peter Hospital (Olympia), and Central Hospital (Seattle). Policies for Group Health Central Hospital are available on Connection: Non-stress testing http://incontext.ghc.org/maternal/documents/FBU.1403.pdf RhoGAM administration http://incontext.ghc.org/nursing_ops/standards/hospnursing/documents/hn-755.pdf MRSA screening http://incontext.ghc.org/clinical/infection_control/procedures/documents/mrsa_obgyn_protocol.pdf

Rh(D) negative women should receive anti(D)immune globulin as indicated.

Prenatal Care Screening and Testing Guideline

Postpartum Care Visit

The routine postpartum visit should take place approximately 46 weeks after delivery; however, an early postpartum visit at 12 weeks after delivery should also be considered for women who delivered by cesarean section or are at high risk for postpartum depression.

Physical examination

Weight Blood pressure Thyroid Breasts Abdomen Pelvic

Routine topics to discuss

Breastfeeding Return to sexual activity Contraceptive plan Emotional status

Screening and testing

Table 7. Postpartum care: screening and testing Test Postpartum depression, PHQ-9
2 1 2 1

Eligible population All postpartum women.

HbA1c (Place order at 4-week postpartum visit.) All women with gestational diabetes. See the Group Health Adult Depression Guideline. The recommendation to use HbA1c as the standard screening test is different from that of ACOG. HbA1c is thought to be a more accurate screening test with less variability between patients. See the Group Health Gestational Diabetes Guideline.

Prenatal Care Screening and Testing Guideline

Evidence/References
Group Health has adopted the recommendations of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists: American Academy of Pediatrics and The American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. Sixth Edition, 2007.

Also reviewed ACOG Committee on Practice Bulletins. ACOG Practice Bulletin No. 77: Screening for Fetal Chromosomal Abnormalities. Obstet Gynecol. 2007 Jan;109(1):217228. Akkerman D, Cleland L, Croft G, et al. Institute for Clinical Systems Improvement. Routine Prenatal Care. http://www.icsi.org/guidelines_and_more/gl_os_prot/womens_health/prenatal_care_4/prenatal_care__rou tine__3.html. Updated July 2012.

References Centers for Disease Control and Prevention. Guidelines for Vaccinating Pregnant Women from Recommendations of the Advisory Committee on Immunization Practices (ACIP) October 1998. (Updated May 2007). www.cdc.gov/vaccines/pubs/preg-guide.htm Malone FD, Canick JA, Ball RH, et al; First- and Second-Trimester Evaluation of Risk (FASTER) Research Consortium. First-trimester or second-trimester screening, or both, for Down'ssyndrome. N Engl J Med. 2005 Nov 10;353(19):20012011.

Prenatal Care Screening and Testing Guideline

Clinician Lead and Guideline Development

Clinical Improvement & Prevention Clinician Lead Paula Lozano, MD, MPH Assistant Medical Director, Preventive Care Contact: 206-326-3938 Guideline Coordinator Avra Cohen, MN, Clinical Improvement & Prevention Guideline Team Members Jane Dimer, MD, Obstetrics/Gynecology Rebecca Doheny, MPH, Epidemiologist, Clinical Improvement & Prevention Robyn Mayfield, Health Education Specialist, Clinical Improvement & Prevention Barbara Schinzinger, MD, Family Medicine Ann Stedronsky, Clinical Publications, Clinical Improvement & Prevention Most Recent Evidence Review June 2012 Process of Development This guideline was adapted from externally developed evidence-based guidelines and organizations that establish the community standards for prenatal care. External sources of recommendations include the U.S. Preventive Services Task Force, Centers for Disease Control and Prevention, Washington State Department of Health, U.S. Department of Health and Human Services, Advisory Committee on Immunization Practices, American College of Obstetrics and Gynecology, and American Academy of Pediatrics. The following specialties were represented on the development and/or update teams: family medicine, obstetrics/gynecology, and preventive care.

Prenatal Care Screening and Testing Guideline

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