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Obstetrics [ADVANCED PRENATAL EVAL]

Ultrasound
The Ultrasound is a great tool. It provides noninvasive imaging
of intrauterine contents. It’s useful to identify gestational age
with a degree of error in weeks equal to the trimester it’s used (1st
trimester is +/- one week, 3rd trimester is +/- 3 weeks). It’s used
primarily to diagnose intrauterine pregnancy, the number of
pregnancies (fetuses), fetal age in gestational weeks, and to
assess for malformations and abnormalities (which can be a
sign of genetic disorders). Finally, as pregnancy nears term (or
mom delivery) it can be used to assess fetal wellbeing. It’s usually
performed routinely in the first trimester (prior to 13.6 weeks) and
second trimester (anatomy scan around 18-22 weeks). It’s also
often performed on labor and delivery to confirm cephalic lie, or
when a biophysical profile is indicated. It’s a free test, is done at
the bedside, and causes no radiation or harmful side effects to
baby.

Umbilical artery dopplers:


Used for monitoring growth-restricted babies. In normal babies,
there’s high end diastolic flow in the umbilical arteries. When the
resistance in the placenta increases, end diastolic flow slows
down and can be absent or reversed in severe cases (indicative of
an increased risk of mortality). A systolic/diastolic ratio is
measured (an increased S/D ratio is abnormal).

MCA Doppler
A specific use of the ultrasound is to assess for fetal anemia.
After 20 weeks an increased flow by intracranial doppler is
indicative of fetal anemia (water flows faster than ketchup - the
thinner the blood, the higher the Doppler speed). It has no risk as
it’s an ultrasound, but it also gives us no access. We can’t know
what the fetal hemoglobin is or provide the fetus any blood. It’s a
great screening tool for patients at risk for developing a fetal
anemia - especially in the setting of alloimmunization. See that
content for more details. If you have the right setup for
alloimmunization you’ll end up getting the Doppler to assess risk;
is it worth it to perform invasive procedures or do we just deliver?

Amniocentesis
Amniocentesis can be used for genetic diagnosis; it can be done
as early as 15-20 weeks. It takes some of the fluid within the
amniotic sac. Baby's cells are floating around in there, which
provides the DNA to do genetic testing. It’s not reliable until 15
weeks. Risks include pregnancy loss (0.1-0.3%, so very low). It’s
used to look at amniocytes (baby's genetic material).
Lab turnaround time is 7-14 days. Amniocentesis USED TO BE
USED to assess fetal anemia using the Liley Graph (this has been
abandoned given the noninvasive MCA Doppler and is always the
wrong answer for anemia). In the same vain, so too has assessing
amniotic fluid for lecithin and sphingomyelin to assess fetal lung
maturity. Now we know the risk of the procedure isn’t worth the
benefit of knowledge. Except for genetic testing, amniocentesis
is always the wrong answer.


© OnlineMedEd. http://www.onlinemeded.org
Obstetrics [ADVANCED PRENATAL EVAL]

Chorionic Villous Sampling (CVS)
Certain moms will have trouble with pregnancy and may warrant
genetic counseling. This is a pretty invasive test, so is reserved
for those who are high risk or desire a diagnosis early. Two types
of patients may want to consider invasive testing of her fetus. The
first is Advanced maternal age (age > 35 years) who have
increased risk of Trisomy: 13 = Patau, 18 = Edwards, 21 =
Down’s. The second is those who have suffered from infants with
birth defects, fetal demise, and intellectual disability. The idea
is if the fetus can be assessed early enough and significant disease
is detected, we can abort it and try again. Chorionic villous
sampling can be done as early as 10-13 weeks but it’s invasive
and carries a risk of fetal demise. The sampling obtains a piece of
the chorionic villus (made from pregnancy tissue) so direct
genetic testing can be performed. The advantage over
amniocentesis is that CVS can be performed earlier in pregnancy
and has a faster turnaround time (lab processing is faster than
amniocentesis). Pregnancy loss is a risk, but is low (0.22%, or 1
in 455).

There are now less invasive ways to test for many of the things
that CVS and amnio are used for. Cell-free fetal DNA is found in
the maternal blood, so many things can be evaluated with a simple
blood draw (this is still considered a screening test, not
diagnostic).

Percutaneous Umbilical Blood Sampling (PUBS)/ Cordocentesis


This is a definitive means of diagnosing and treating fetal
anemia. It’s like putting an IV into the baby while baby’s still in
the uterus. A blood sample to determine the exact hemoglobin can
be obtained and there’s access to transfuse blood. This is the last
step in the evaluation of fetal anemia. The MCA doppler will be
positive (elevated), there will be fetal anemia, and now the baby
must be transfused to survive. This is rarely the right answer; look
for a very well-worked-up fetus that isn’t ready to deliver. It can
be performed at > 20 weeks, and typically isn’t done after 32
weeks (just deliver then).

Procedure Gestational Age Goal Risk of Loss Bonus


Ultrasound Any Intrauterine Pregnancy No risk 1st Trimester +/- 1 week
Fetal age 2nd Trimester +/- 2 weeks
Fetal Well-being 3rd Trimester +/- 3 weeks
Transcranial Doppler > 20 weeks Screen for fetal anemia No risk No access (compare to PUBS)
(Alloimmunization)
Amniocentesis > 16 weeks AFP, Genetics, fetal 0.1-0.3% > 16 weeks: Genetics
lung maturity, assess > 24 weeks: Liley Graph
for infection > 36 weeks: L:S ratio
Chorionic Villous 10-12 weeks Genetics, Karyotyping 0.22% None
Sampling
Percutaneous Umbilical > 20 weeks Confirm Fetal Anemia Access for transfusion
Cord Sampling AND Treat Fetal Anemia
< 32 weeks Just deliver if > 32 weeks

Listed in order of risk ascending order of fetal demise


© OnlineMedEd. http://www.onlinemeded.org