Wednesday, March 1, 2017

Streamlining Prenatal Services

Especially with the new trend toward high-deductible insurance plans, the cost of pregnancy can be staggering. There are a lot of optional tests and services during the prenatal period. I chose a streamlined schedule with visits only every 4-5 weeks (until end of third trimester), limited genetic testing, and only one ultrasound. You should discuss all services carefully with your treating provider (doctor or midwife). 

Read on for the service schedule I followed during both my pregnancies...

It's important for me to share that I had no big complications during either of my pregnancies, I don't really consider breech a complication :-). Especially during first trimester, I never experienced cramping or spotting, I did not suffer hyperemesis or much morning sickness, etc. My blood pressure and baby's heart rate were within normal range at all my checkups and I had no abnormal lab work (except my first failed glucose test during second pregnancy which is a different story).

The following is the prenatal service plan I followed for both my pregnancies (bold items are discussed in more detail below):

5-6 Weeks: Confirmation of Pregnancy, Required Labs
10 Weeks: Prenatal Visit, Hear Heartbeat, Chromosome Screening
14 Weeks: Prenatal Visit
19 Weeks: Prenatal Visit, Anatomy Ultrasound
24 Weeks: Prenatal Visit
28 Weeks: Prenatal Visit, 1-Hour Glucose Test, Required Labs
32 Weeks: Prenatal Visit, DTaP Vaccine
34 Weeks: Prenatal Visit
36 Weeks: Prenatal Visit, Group Beta Strep Testing, Required Labs, Check Cervix
37 Weeks: Prenatal Visit
38 Weeks: Prenatal Visit
39 Weeks: Prenatal Visit
Labor and Delivery!

At your first visit, your physician will run a urine test and feel your uterus to confirm pregnancy. With both my pregnancies, my doctor cheerfully told me "feels like a 5 (or 6) week uterus!" and I took her at her word. 

At 10 weeks (depending on your weight) baby's heartbeat can be heard by a hand-held dopplar. I heard my baby's heartbeat for the first time at 10 weeks with both my pregnancies and at every visit thereafter.

Required Labs
Laboratory testing is required at several stages during pregnancy and is typically not optional. My clinic tested labs at pregnancy diagnosis and at 28 weeks including STD testing (which is frequently state-mandated for syphilis and HIV) and a complete blood count (CBC) which checks for infection, iron level, and blood counts. These were blood draws in the laboratory. At 36 weeks they also checked my urine and hemoglobin level (pee in a cup and finger stick, no laboratory blood draw).  

A first trimester ultrasound (viability scan) will show the size of the baby as well as the presence of cardiac activity. It can be used to establish dates of pregnancy, diagnose an ectopic pregnancy (fertilized egg is implanted somewhere other than the uterus), confirm a miscarriage, or view the uterus. 

The second trimester ultrasound (anatomy scan) is performed at 18-20 weeks and will show the location of your placenta and all of baby's anatomy! You can see blood flow through the chambers of the heart, brain, and kidneys. The spine can be fully visualized. It really is remarkable!

A third trimester ultrasound can be used to check fetal growth, check amniotic fluid level, assess the placenta, and check the position of the fetus. I had several of these with my first pregnancy (starting at 37 weeks) because my baby was breech.

My hubby and I at our ultrasound visit with baby #2. The tech yelled at him for taking a picture during the scan...apparently that is not allowed!

Genetic Screening
If you are over 35, a chromosome screening test will be offered at 10 weeks. This was by far my favorite test and the only genetic screening I did. I had the MaterniT21 with my first pregnancy and the Panorama with my second. Both tests separate baby's DNA from your own blood sample to look for chromosome abnormalities (additions or deletions). The most common chromosome abnormality is Down's Syndrome. The test will also tell you the sex of the baby (as that is determined by baby's chromosomes). I really liked finding out the sex at 11 weeks! 

Prior to chromosome screening, the screening blood test most commonly done was Alpha-fetoprotein screening (AFP). AFP is a protein located in the amniotic fluid which crosses the placenta to the mother's blood. Abnormal levels can indicate spina bifida, chromosome abnormalities, and abdominal wall defects. The AFP test is usually done between 15 and 17 weeks of pregnancy. You'll notice on my schedule I did not have a visit during those weeks. I chose instead to come back at 19 weeks for my anatomy ultrasound. My doctor's advice was that AFP testing would not reveal anything that would not have already been seen on the chromosome screening or anatomy ultrasound. I think I may have elected to have the AFP screening done at 15 weeks had I not been eligible for the chromosome screening at 10 weeks.

The American College of OB/GYN (ACOG) recommends cystic fibrosis (CF) carrier screening be offered to all parents. This is a blood test or mouth swab done on you and your partner during first trimester. It is usually strongly recommended if you or your partner have a family history of CF. Other risk factors are race related, Caucasians with ancestry from Northern Europe have the highest rates of CF carrier status.

If you have positive results to any of the above genetic screening tests, additional testing options include Amniocentesis and Chorionic villus sampling (CVS). These tests have risks to both you and baby and should be carefully discussed with your physician.

Glucose Testing
For the 1-hour Glucose test you drink a small bottle containing 50 grams of Dextrose (sugar) and then have your blood sugar level tested 1-hour later to see how your body responded to the sugar. Glucose testing is mandatory at my clinic practice. I've heard some clinics offer other options, such as taking a glucose monitor home and checking your blood sugar for two weeks. 

If you fail the 1-hour Glucose test, you'll be referred to take the 3-hour Glucose test. For the 3-hour test you have a fasting blood draw (first thing in the morning), then you drink the same size drink as the 1-hour, but it contains 100 grams of Dextrose (sugar). You then have your blood drawn every hour for 3-hours to see how your body responds to the sugar.

If you fail the 3-hour Glucose test, you will be referred to a diabetic clinic for evaluation of gestational diabetes. There is some additional information in my post HERE.

Group Beta Strep (GBS)

This test is just a vaginal swab done at 35-37 weeks. Approximately 25% of healthy women will test positive for GBS. GBS typically causes no complications outside of pregnancy. GBS is the most common cause of life-threatening infections in newborns. If you are GBS positive, your doctor will recommend you receive antibiotics during labor to prevent infection in baby. 

Cervical Check
There should be no fee for a cervical check. My office offers optional cervical checks at each visit starting at 36 weeks. I had initial cervical checks during both pregnancies. I was already undressed for the GBS swab anyway. With my first pregnancy (breech), I was checked at 36 and 37 weeks and both checks were uneventful, I was told I wasn't dilated or effaced at all, and at 37 weeks that baby was breech (My Breech Baby Story). With my second pregnancy, baby had dropped at the start of my 36th week and his head was already putting a lot of pressure down there. I found the cervical check very uncomfortable. I was 80% effaced and 2 cm dilated. The day following the check I had some spotting, likely due to mucus plug disruption or just plain cervical irritation from the check. I'm electing to not have additional checks. What my physicians have told me is that no matter what a cervical check shows, there is nothing that will predict if you are going to go into labor or not. Women can walk around partly effaced and dilated several centimeters for weeks. Now, if you are having signs of labor already, that is a different story.

Sometimes I feel like I'm being pushed out the door at my clinic! The sad truth is that physicians only have very small windows of time to see you and stay on schedule. But their pressing schedule should not effect your level of care. Make sure all your questions are answered!

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