Optimizing Early Prenatal Care for Your Patients: Whats new on the - PowerPoint PPT Presentation

Optimizing Early Prenatal Care for Your Patients: What’s new on the Ontario Perinatal Record? Dr. Miranda Sheppard Dr. Nisha Arora Ms. Wendy McCrady Wednesday May 9, 2018

Learning Objectives 1. To review investigations in the first trimester including: dating ultrasound, prenatal screening, early diabetes screening 2. To review which immunizations are indicated in pregnancy, including pertussis and influenza, and how to assess rubella immunity. 3. To understand how and when to prescribe aspirin to your pregnant patient.

Presenter Disclosure Faculty: Miranda Sheppard, Nisha Arora, Wendy McCrady Relationships with commercial interests: none Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none Other: none

Disclosure of Commercial Support This program has not received financial support or in-kind support. Potential for conflict(s) of interest: none

Mitigating Potential Bias Not applicable.

Prenatal Investigations Immunizations Agenda Aspirin Discussion

Prenatal Investigations

When is your patient due? Earliest T1 scan with CRL 10-84mm is best parameter LMP underestimates US-based EDD by 2-3 days US dating reduces IOL by 70% compared to “certain LMP” (in both T1/T2) T1 scan should be offered to all, can be combined with scan for NT Composite age on T2 scan (<23wk) more accurate than LMP SOGC Clinical Practice Guideline. Determination of Gestational Age by Ultrasound, JOGC, February 2014

Prenatal Screening Screening should be offered, regardless of maternal age Discuss risks, benefits, alternatives 1) No screening 2) Standard prenatal screening → now eFTS (or MSS if presenting 14-20+6wk) 3) US-guided invasive testing, when appropriate 4) NIPT (maternal plasma cell-free DNA screening) - may not be covered by OHIP Joint SOGC-CCMG Guideline: Update on Prenatal Screening for Fetal Aneuploidy, Fetal Anomalies, and Adverse Pregnancy Outcomes, JOGC, Sept 2017

Still offer T1 Ultrasound Offered regardless of screening test chosen Viability, GA, multiples & choronicity, early anatomy, NT eFTS should not be done if NIPT being done Not indicated solely to detect higher risk of adverse pregnancy outcomes Joint SOGC-CCMG Guideline: Update on Prenatal Screening for Fetal Aneuploidy, Fetal Anomalies, and Adverse Pregnancy Outcomes, JOGC, Sept 2017

What is eFTS?? Screens for T21, can flag high T18 risk Placental growth factor & T1 alpha fetoprotein added to PAPP-A and beta hCG; combined with NT & patient history Still done 11+0 to 13+6wk DOES NOT screen for NTD/spina bifida Good quality T2 US more accurate, consider AFP if BMI >35 IPS can no longer be ordered at LHSC (Jan 2018) SOGC Clinical Practice Guideline. Prenatal Screening, Diagnosis, and Pregnancy Management of Fetal Neural Tube Defects, JOGC, Oct 2014

Down Syndrome and Live Birth Rates ONTARIO 2005-2013 - 20% of live births to woman 35y+ (23% BC, 21% YK) Public Health Agency of Canada (2017). Down Syndrome Surveillance in Canada 2005-2013

eFTS: How does it compare? Screening Test Detection Rate False Positive Rate Current FTS 78-85% 8-9% 9% Enhanced FTS 85-90% 3-6% (eFTS) eFTS (no NT ) ~80% ~5% IPS 85-90% 2-4% MSS (quad 75-85% 5-10% screen) Trillium Health Partners. Enhanced FTS Information FAQs. Accessed Mar 22, 2018

eFTS is positive, now what?? Counsel patient - remind eFTS is screening test, additional screening/diagnostic tests available 1. cfDNA → MD/NP can order, refer to genetics if + screen 2. If pt would not be reassured by neg cfDNA (2nd screening test) → offer referral to genetics CVS (11-13wk) SA risk 1% ● Amnio (15-17wk) SA risk 0.01-0.5% ● Results: QI-PCR 2-3d, microarray 2wk, single gene test 2-6wk ● Carroll, J. et al. (Aug, 2007). Reference Guide for Health Care Providers Prenatal Screening Tests for the Detection of: Down Syndrome, Trisomy 18 and Open Neural Tube Defects..

eFTS is positive, now what?? NT >3.5mm in T1 → REQUIRES GENETIC COUNSELLING Will be offered additional testing Risk T21, T18, T13, XO Risk microdeletions, other chromosome anomalies (genetics will offer microarray, karyotype) Risk single gene conditions Risk structural fetal anomalies, esp cardiac

cfDNA testing/NIPT STILL A SCREENING TEST ~10wk GA mean amount of circulating fetal cfDNA 10% in maternal serum ● Can be performed after 9wk GA ● Turn-around-time 10 business days ● Harmony (Gamma Dynacare), Panorama (Life Labs) ● Considered equivalent ○ Can be used with twins but data limited ○ NOT to be used with “vanishing twin” or twin demise ○ Primary Care Provider can order ● >= 40 years at EDD ○ Abnormal serum screen i.e. eFTS/MSS ○ NT >= 3.5mm or greater → consider direct referral to genetics ○ Previous pregnancy/child with aneuploidy ○

What does a positive NIPT result mean? T21 99% detection rate, <1% false positive ● PPV 90.9% ● T18 28,739 samples 96.4% detection rate, <1% false positive ● PPV 93.1% ● 82.9% PPV for all T13 aneuploidies 99% detection rate, <1% false positive ● PPV 38.1% ● Monosomy X 92.9% detection rate, <1% false positive ● PPV 50.0% ● Dar, P. et al. (2014). Clinical experience and follow-up with large scale single-nucleotide polymorphism-based noninvasive prenatal aneuploidy testing. Am J Obstet Gynecol 211(5): 527.

Failed NIPT Results Increased BMI, early GA → lower fetal fraction ● Can order repeat sample x1 ● If failed x2 → suggest another form of screening or diagnostic testing ● Aneuploidy can have lower fetal fraction ○

Prenatal Screening - Twin Pregnancy eFTS - PAPP-A and beta hCG; combined with NT & patient history ● Previously risk quoted based on NT alone ○ 85% detection rate, 5% false positive rate ○ eFTS will report ONE risk for a twin pregnancy ● Monochorionic → the chance that both affected ○ Dichorionic → the chance that one or both affected ○ If twin demise or “vanishing twin” ● NYGH advises against eFTS, suggest NT and MSS instead ○ Can call lab to discuss individual cases ○ North York General Hospital. (Feb, 2017). Enhanced-FTS for TWINS - FAQs Handout.

Abnormal US findings NT >3.5mm in T1 → REQUIRES GENETIC COUNSELLING , offered additional ● testing, detailed T2 US with good heart views If negative eFTS - “soft markers” associated with fetal trisomy 21 (echogenic ● intracardiac focus) or trisomy 18 (choroid plexus cysts) ARE NOT clinically relevant (poor PV) and DO NOT warrant further testing Fetal structural abnormality → requires genetic counselling/FDC referral ● Joint SOGC-CCMG Guideline: Update on Prenatal Screening for Fetal Aneuploidy, Fetal Anomalies, and Adverse Pregnancy Outcomes, JOGC, Sept 2017

Prenatal Screening Resources Genetics Education Canada - Knowledge Organization (GEC-KO) ● “Guide to Understanding Prenata Screeningl Tests” (21page PDF) ○ http://www.geneticseducation.ca/uploads/Prenatal_screening_Public_Brochure_ONTARIO_Jan2018_v2.pdf ○ North York General Hospital Prenatal Services ● Prenatal Screening Requisition ○ http://www.nygh.on.ca/data/2/rec_docs/2978_MSS_Requisition.pdf ■ eFTS for singleton and twin pregnancies info sheets ○ http://www.nygh.on.ca/data/2/rec_docs/2720_FAQ_eFTS_Singleton_Feb_2017.pdf ■ http://www.nygh.on.ca/data/2/rec_docs/2721_FAQ_eFTS_Twins_Feb_2017.pdf ■

Does your patient have diabetes? If there is a high risk of gestational diabetes mellitus based on multiple risk factors, screening or testing should be offered during the first half of the pregnancy and repeated at 24 to 28 weeks’ gestation if initially normal. Almost 25% of the time, GDM can be diagnosed before 24weeks.

When to screen early for diabetes ● maternal age > 35 years ● obesity (pre-preg BMI > 30) ● ethnicity (Aboriginal, African, Asian, Hispanic, South Asian) ● family history of diabetes ● polycystic ovary syndrome ● acanthosis nigricans ● corticosteroid use ● previous pregnancy complicated with GDM ● previous macrosomic infant SOGC 2016

Immunizations

Ontario Perinatal Ontario Antenatal Record 2017 Record 2005

Benefits of Immunizations in Pregnancy ● Protect pregnant woman : altered immune response - increased risk for infection and severe outcomes if infected. Pregnant women respond adequately to vaccines even though pregnancy is an immunologically altered state. ● Protect fetus : passive immunity - maternal antibodies transferred to fetus transplacentally, majority during T3 ● Protect neonate and young infant : passive immunity through colostrum/breast-feeding; prevents mother from acquiring infection that may be passed on to newborn baby

General Considerations ● Are vaccines safe for pregnant women and their fetus if given during pregnancy? ● Do vaccines provide effective protection to pregnant women if given during pregnancy? ● Does vaccinating mothers increase the protection of infants? ● Does maternal antibody transferred across the placenta interfere with neonatal immune response to immunization?