Congratulations on your new pregnancy! We realize what an exciting time this is for you, and look forward to working with you to make this a joyous event. Thank you for choosing our practice.
At your first or second obstetrical visit, you will be given a purple packet with handouts and information regarding your pregnancy. Should you need to refer to these materials and don't have your packet with you, you can check the information here.
Schedule of prenatal visits
Please call the office as soon as you think you might be pregnant. Once the pregnancy is confirmed, schedule your first prenatal visit. This visit will take a little longer than usual, for it involves reviewing your history, performing a physical exam and pap smear as necessary, ordering blood work, and discussing a wide variety of topics to get the pregnancy off to a good start.
In general, you will be seen every 3 weeks until you are 28 weeks pregnant, every 2 weeks from 28-36 weeks, and then weekly until 41 weeks, which is one week after your due date. These visits will involve checking your weight, urine for protein and sugar, blood pressure, monitoring the growth of your fetus, reviewing your diet, and discussing any problems and concerns which you may have. After 41 weeks, we will see you twice a week. These visits will involve ultrasounds and fetal monitoring to make sure your baby continues to be healthy.
If your pregnancy develops complications, you will, of course, be seen more frequently.
What tests will be done?
Usually the initial prenatal labs include a blood count, a blood type and determination of your Rh status, an antibody screen to check for unusual red blood cell antibodies, a test to see if you are immune to rubella (German measles), and tests for syphilis and hepatitis B. If you don't know if you have had chickenpox, we will check that too. An HIV test will be recommended. Depending on your ethnic background, we might order a hemoglobin electrophoresis to check for sickle trait or thalasemia.
Genetic Screening and Testing
If you want genetic screening or testing, this will be done during the late first trimester or early second trimester. This might include chorionic villus sampling (CVS), amniocentesis, First Trimester Risk Assessment or Maternal Quad Screen. Depending on your medical, family and obstetrical histories, as well as upon your age, genetic counseling, screening or testing are offered to you. Genetic counseling may be as simple as a review of your family history and a few specifically targetted screening questions during your initial obstetrical visit or as extensive as a consultation with trained genetic counselors and perinatologists for amniocentesis or DNA carrier testing.
The goal of all genetic testing is to identify those babies who are at risk for medical problems in pregnancy and after birth. People tend to think of testing as only for Down Syndrome, but many disorders which occur spontaneously or run in families can be diagnosed before birth. Some families may want to have this information, while other families do not choose to know ahead of time. This is your personal decision.
One of the simplest and easiest genetic screening tests is the ultrasound. Ultrasound can be used to evaluate the physical characteristics of the fetus which may help predict certain abnormalities. Measurements of various body parts can be used to suggest an increased risk of Down Syndrome, can look for congenital defects such as spina bifida or leaky heart valves, and birth defects such as cleft lip or club foot. Ultrasound is both an adjunct to other testing such as amniocentesis, and a genetic screening test in its own right. Ultrasound carries no risk of which we are aware, but does not provide the highest levels of assurance desired by some parents, because it relies on physical characteristics alone. Ultrasound is also used for other evaluations of the fetus not involving genetic screening. It may be used to check the position of the fetus in the uterus, monitor fetal growth, locate the placenta, evaluate the fluid around the baby or evaluate the fetus' behaviors such as breathing, movement and muscle tone.
First Trimester Risk Assessment
First trimester screening is based on three parameters: maternal age, nuchal translucency (the thickness of the back of the fetus’ neck) measured by a specially trained and certified sonographer, and analysis of proteins in the mother’s blood. The results are expressed as your mathematical odds of having a baby with Down Syndrome or Trisomy 18 which are chromosomal abnormalities. First trimester screening only assesses risk for Down syndrome and trisomy 18. It does not predict the risk of a neural tube defect. It is done between 11 and 14 weeks. There is no risk to having this test. If you are at increased risk of having a fetus with Down Syndrome or Trisomy 18, it does not mean that your fetus has one of these conditions. It means you are offered additional testing such as CVS, detailed ultrasound or amniocentesis.
Maternal Quad Screen
Another screening test is the Maternal Quad Screen. It is not quite as accurate as the First Trimester Risk Assessment, since it does not detect quite as many cases of Down Syndrome or Trisomy 18, and has slightly more “false positive” tests. The Maternal Quad Screen tests for four chemicals in the mother's bloodstream. Maternal age is also considered in calculating the results of this test. The test is performed around the sixteenth week of pregnancy, and there is no risk to the test. The results are expressed as your mathematical odds of having a fetus with Down Syndrome, Trisomy 18 or Neural Tube Defect like spina bifida. If you are at increased risk, it does not mean that your baby has one of these conditions. It means you are offered additional testing such as a detailed ultrasound to check the fetus’ anatomy and an amniocentesis to test the baby’s chromosomes. You may accept or decline these tests.
In those pregnancies in which the Quad screen is abnormal, but the followup testing shows a normal fetus, there may be a greater risk that the pregnancy could be complicated by poor growth of the fetus, by preterm delivery, by pregnancy-induced hypertension or toxemia. Therefore, if you decide to have the Quad Screen, you may be able to obtain information that allows you to take steps either to prevent or to reduce the possibility of other complications. Fetal testing in the third trimester may be offered.
Ultrasound, First Trimester Risk Assessment and Maternal Quad Screen are screening tests. There are designed to assess your risk of having a fetus with a problem. Should you wish a higher level or certainty, there are two tests which will tell you your fetus’ exact chromosome. Because these tests have small risks associated with them, they are generally offered to women who will be 35 or older at the time of birth, have had a previous child with a chromosome abnormality, or have a family history of chromosome abnormalities.
Amniocentesis (or amnio) is a procedure usually done at approximately 16 weeks gestation for genetic evaluation of the fetal chromosomes. Amnio may be done at other points in a pregnancy for other reasons, but for genetic testing the second trimester is ideal. Using ultrasound guidance, the doctor inserts a needle through the maternal abdomen and into the uterus. A small amount of amniotic fluid is withdrawn. The amniotic fluid contains cells from the baby's body, and these are grown and the chromosomes are studied. The results of the study are usually available in about 7 - 10 days. In addition to the chromosome information, a protein called alpha fetoprotein is measured in the amniotic fluid. This may help diagnosis a neural tube defect such as spina bifida.
As with any medical procedure, an amniocentesis carries some risks. The major risks are rupture of membranes, bleeding and infection. These are rare, but if they occur, it may cause loss of the pregnancy. Complications occur in about 1 of every 400 amniocenteses.
Chorionic Villus Sampling
Some parents don't want to wait until 16 weeks for genetic testing. A chorionic villus sample (CVS) can be done at an earlier time in the pregnancy, usually around 11 weeks. CVS, like amniocentesis, is offered to women who will be 35 or older at the time of the birth, or with a family history of a child with a chromosomal abnormality.The cells collected in the CVS procedure are from the baby's placenta. A catheter is generally passed through the mother's cervix, and some of the cells are withdrawn. Sometimes a needle is passed through the mother's abdomen and cells are withdrawn from the placenta. Results are generally ready in 3-4 days. CVS does not measure the amount of alpha fetoprotein in the amniotic fluid, so if you want to know your risk of having a baby with a neural tube defect, you should consider having a blood test to measure the AFP. This is done between 15-18 weeks.
Like amniocentesis, CVS is done under ultrasound guidance. The risk of ruptured membranes, bleeding or infection is about 1 in 400. Both procedures are done by the perinatologists at Yale-New Haven Hospital.
Remember, these tests are optional. It is up to you and partner to decide whether you want any screening or testing during your pregnancy. If you decide that you would like to have the First Trimester Risk Assessment or Maternal Quad Screen, we will fill out the forms for you during an office visit. If you decide to have an amniocentesis or CVS, please contact Yale Genetics at 203-785-2661 to make an appointment. Please let us know the date of your appointment so that our billing staff may assist you in getting any pre-authorization or pre-certification which your insurance company might require.
Between 25 and 28 weeks, we will check your blood count, offer an HIV test, check again for syphilis (as required by Connecticut state law), and do a glucose screening test to make sure that you do not have any problems with breaking down blood sugar. Because of a hormone put out by the placenta, some women cannot metabolize glucose as well during pregnancy. If the mother's blood sugar is too high throughout the end of her pregnancy, the fetus can grow too big, and can have problems maintaining its blood sugar following birth. Babies with very low blood sugar can have problems with seizures, maintaing their temperatures, and adapting to life outside the uterus. If the mother's blood sugar is within normal range during pregnancy, the fetus generally does very well.
Because of the problems which elevated maternal blood sugar levels can cause to the fetus and newborn, we will check your ability to metabolize, or break down, glucose. Between 25 - 28 weeks, we will ask you to drink a sweet sugar solution and one hour later, we will draw a sample of blood to check your glucose level. If the glucose level is normal after one hour, no further testing is done. If the glucose level is high, we will ask you to have a 3 hour glucose tolerance test (GTT). If 2 of the values ( one, two and three hours after drinking the glucose solution) OR the fasting glucose on the three hour test are elevated, we will consider that you have gestational diabetes.
Group B Strep
Group B beta-hemolytic streptococcus (GBS) is a very common bacteria. It resides in the gastrointestinal tract of up to 40% of men and women. In women it can grow in the urinary tract or reproductive organs as well. People who have this bacteria are said to be "colonized", or are called "carriers". There is no way to permanently get rid of GBS. It tends to come and go, and rarely causes symptoms in adults.
Why is this important during pregnancy? 15-40% of women are colonized with GBS during their pregnancies. Usually there are no symptoms, and colonization may come and go. GBS is not treated during pregnancy unless it is present in high amounts in the urinary tract.
If the mother passes GBS to her baby, the baby may develop GBS infection. For those few babies (0.5 - 1% of babies born to colonized mothers), there can be serious problems. GBS infection in the newborn can cause infections of the blood stream, brain or lungs. This is very rare, however. Approximately 99% of babies exposed to GBS do not become infected. The babies that are most likely to be infected are premature, or have prolonged rupture of membranes.
The best way to try to prevent GBS infection in the baby is to treat the mother with antibiotics during labor, if she has a positive culture or if she has certain risk factors during labor. Treating the woman before labor cannot be relied upon to prevent infection in the baby, and is not advised. There is no recommendation to treat GBS in the vagina during pregnancy.
In this practice, we will obtain a GBS culture from the outer part of your vagina and from your rectum. This will be done between 36-37 weeks of pregnancy. If this culture is negative, you will not need any antibiotic treatment in labor. If this culture is positive, or if you have had a GBS urinary tract infection or a previous baby infected with GBS, iv antibiotics will be given during your labor.
For more information on GBS, you might want to visit the CDC (Center for Disease Control) web page at http://www.cdc.gov/groupbstrep/index.html
If you are Rh negative
There are 4 main types of blood : A, B, AB and O. In addition, each of these main types may have an additional protein called the Rh , or rhesus, factor. This is a protein which is attached to your red blood cells. Your blood type is either A+, A-, B+, B-, AB+, AB-. O+. O- depending whether or not you have the Rh factor. The incidence of the Rh factor varies in different ethnic groups. Approximately 85% of people in the United States have the Rh protein, and are called Rh positive (Rh+). The remaining 15% are called Rh negative (Rh-).
The baby often has a different blood type than its mom. Most of the time this is not a problem; however, if some of the baby's blood mixes with the mom's blood during pregnancy, the mom may recognize this blood as foreign, and develop antibodies against it. The time when this is most likely to happen is around the time of birth; however, it can happen at other times during the pregnancy as well.
If Rh positive blood from the baby gets into the mother's bloodstream, the mother recognizes this foreign protein , and makes antibodies against it. The antibodies attack the Rh positive red cells and destroy them. This is rarely a problem during that pregnancy, but can cause serious problems in future pregnancies, when these antibodies can cross the placenta and attack the developing red blood cells in the fetus.
There is a medicine called Rhogam which we give to Rh (-) women who have Rh(+) partners. Rhogam "blocks" the formation of antibodies, and prevents breakdown of the fetal red blood cells. Rhogam is given if there is bleeding during pregnancy, after amniocentesis, at 28 weeks gestation and also following the birth of an Rh(+) baby.
When to call - warning signs during pregnancy
At any time during pregnancy you should call us if you have
- fever (more than 100 )
- painful urination
- vomiting that lasts more than 24 hours
- severe headache that is not relieved by tylenol (acetominophan)
- blurry vision or flashing lights in front of your eyes
- leaking fluid from the vagina
- contractions that do not stop right away when you get off your feet and drink water (unless you are more than 36 weeks - contractions are normal then)
- decreased fetal movement
- you are scared or worried that "something isn't right"