Manual of
Laboratory, X-Ray and Special Procedures (from the New York
Hospital - Cornell Medical Center)
Canterbury Health
Laboratories - Handbook of Tests
Content of Prenatal Tests - OB opinions
Timing of Prenatal Tests - OB opinions
How
to…
interpret basic blood values in pregnancy - Thames Valley
University’s senior lecturer in midwifery Maureen Boyle explains
how to analyse blood results during pregnancy.
Laboratory
Testing During Pregnancy
The state tells us (since we are licensed midwives) what labs to do, and this is what we get on all women:
CBC, Rubella titer, ABO and RH, antibody screen, UA, urine culture, HBSag, RPR. Though not required by the state we also do HIV and Hep C antibody. Our price from the lab is less than $40. We negotiated this.
State requires pap and GC, so we do the pap, (cost $12.) and a
GC/Ch DNA probe (less than $25.)
No need for routine glycosuria/proteinuria screen in pregnant women. William A. Alto, MD, MPH
Practice recommendations
Screening for gestational diabetes using urine dipsticks for glycosuria is ineffective with low sensitivities. False- positive tests outnumber true positives 11:1. A 50-g oral glucose challenge is a better test. Tests for glycosuria after this blood test are not useful (B).
Proteinuria determined by dipstick in pregnancy is common and a poor predictor for preeclampsia with a positive predictive value between 2% and 11%. If the blood pressure is elevated, a more sensitive test should be used (B).
After urinalysis at the first prenatal visit, routine urine
dipstick screening should be stopped in low-risk women (B).
Great
handout about Urinalysis by Jane Trapp PA-C
Abnormal
Urine Color [Medscape,
1/31/12]
Maternal
urine
albumin excretion and pregnancy outcome.
Franceschini N, Savitz DA, Kaufman JS, Thorp JM.
Am J Kidney Dis. 2005 Jun;45(6):1010-8.
CONCLUSION: Low levels of albuminuria are associated with preterm
birth. The mechanism underlying this association warrants
additional exploration.
Another round of discussion in Spring, 2010:
I have a question regarding use of urine dip sticks during
routine prenatal visits. Studies indicate that it isn't a reliable
indicator for complications of pregnancy. So, I am wondering if
most practitioners who practice out of the hospital are still
using them. So, for my practice has always used them, now I'm
questioning the validity.
I don't work in hospital, but I stopped doing routine dips about
ten years ago when the gov report came out saying it was not worth
doing.
i know a few hospital-based CNMs who don't do them routinely.
I do them for 'indications only"...
Definitely yes, urine is tested at each prenatal visit for
protein and glucose, and most practitioners also test for nitrites
and leukocytes for an occult UTI also. It would be considered
against the standard of care not to.
I look at it this way: it doesn't hurt anything (non-invasive) to pee on a stick, it reassures some clients, it makes your charts more defensible to the "standard of care" if that is ever a concern for you or your clients (think transport from the clients' point of view), and most important to me - if it catches even one occult UTI in time for me to head it off with herbs/diet before a mom needs antibiotics (prevention, right?), then the relatively small cost was well worth it. So I do it.
After all, other than the price of the sticks, is there a down
side?
Stopped using them as well. Local in-hospital CNM practice no longer uses as well, though one CNM said they had to do a lot of talking to clients as some clients felt they were not getting all the care they would with MDs.
Our practice stopped using them years ago, except initially and
for indications. However, at the local hospital prenatal clinic
they still use them. Habit, I think.
I asked my collaborating doc if I could forego doing them
(hospital practice) and she said "no".
We have stopped using them at our birth center. It is no longer
recommended as a standard of practice. Anyone who you suspect of
PIH should have a 24 hr urine collection, not just a dipstick. As
far as the other tests on the dipstick, such as leukocytes or
glucose, we all know there are far too many false positives with
these to rely on them for diagnosis.
Friends who practice at midwifery clinics within major academic
hospitals report that they're no longer using them either. Not
evidence based, they told me.
I gave mine all the supporting information and she said "as long
as using them is the standard of care we will do it"
What is it about evidence based practice the older OBs don't get?
Stopped using them years ago. Not evidence based and no longer
used in most European countries. Continued here in places, I would
guess, per legal counsel.
A couple of the CNMs from our area attended a conference a few
years ago where urine dipsticks came up--the presenter asked if
anyone was still using them, and these midwives reported they were
the only ones raising their hands! Conversely, I attended an
in-hospital presentation by a physician who had researched urine
testing in pregnancy, and her take was that there should be less
use of urinalysis, and use of the dipsticks as they were good
indicators of urinary tract infection. Blue Cross and Blue
Shield require they be used at each visit, and it is checked when
they do a site visit.
The practice I works in uses them in 2 occasions: 1) client
complains of UTI symptoms or 2) client insists or prefers. They
are still used routinely at all OB visits in this area. Sometimes
clients who have had their babies with an OB are upset if we don't
offer to dip their urine each time so we will for them, Otherwise,
no. It is not evidence-based practice to rely on this as a routine
screening tool.
What about how I can get a feel for her hydration level,
nutritional status and her ability to fight disease? (ketones,
gravity, ph) Urine can tell you a lot! after 15 years of
habit how can i stop?
You can assess this without the sticks. I always had the
women dip their own urine and it gave them a sense of control over
their own bodies and something to do when they entered the
office--habit.
The military (Air Force) clinics had stopped using them at least
5 years ago, when I was making site visits to our midwifery
students there.
Wouldn't 10s be more useful in screening for UTI, assessing
hydration status in hyperemesis etc.
I love dipping my ladies. I use the 10SG because I am nosy. I can see if they have been drinking plenty of fluids (#1) which can cause blood in the urine (sex the night before may show blood also) & help them to avoid the dreaded kidney stones. I can pickup nitrates (& treat it and save them & me much misery in the last month of pregnancy) and see if they are having liver problems (upset tummies, nausea, vomiting). I can see if they are dieting (ketones). Yes, I see sugar and find out what they ate and will easily discount sugar especially if their OB history shows small babes but also advise them to watch eating so many carbs that turn into sugar (& saps their energy). I NEVER give oral glucose. I'll do a fast (being at their home at 5 am) or postprandial.
Everyone is dipped on the initial. Once we go to home
visits we do not dip unless office visits showed abnormals or they
have s/s of problems.
Ok, so here is why I spend the extra bucks for the 10sSG. First of all, I just love the SG. My clients check their own urine and many times will have a concentrated specimen. No matter how much I tell them to increase their fluid intake they never listen 'till they see it on the stick :-) They come out of the bathroom saying "oops, I guess I need more water huh?" Worth every penny to me.
I also don't do routine blood sugars. If a mom spills sugar on the stick then we review the diet. If she does it twice then we do the 1hour pp. I tell them that many moms just spill sugar but it will also pick up diabetes if blood sugars are >175-180.
We basically ignore leukocytes unless they are associated with proteinuria and/or blood. We try to rule out vag infections. We tend to be pretty aggressive with nitrites.
We like to see ph at ~7. Urine that is too alkaline provides a perfect environment for bacteria to grow.
Bilirubin and Urobilinogen can show that the liver is starting to get compromised. If one of these shows up we will put the moms on herbs to help strengthen the liver.
Some moms will spill a trace of protein at every visit. We basically ignore them unless they go 1+ or higher, or they are associated with leukocytes or nitrites.
I rarely see ketones but when I do I usually will jump all over
the mom about her diet. The presence of ketones means that the mom
is burning into her fat reserves. Ketones can also indicate
dehydration. Either way, ketones are not a good sign during
pregnancy.
A rather 'progressive' hospital here (Brisbane) has basically
dropped weighing the mum, routine urine testing, and fundal/ girth
measurement. I believe this has been a research-based decision.
I am thrilled to see this. As midwives, especially OOH or DEM's,
we are really risking ourselves and our clients if we go out of
community standards. But if the hospitals, and thus the docs do
it, then we can follow suit swiftly. Even if just one hospital in
your area does it, it disrupts the community standard enough to
CYA. Hurrah....
I think this is very interesting -- i wrote my master's
thesis on the origins of prenatal care (mostly looking at what the
Maternity Center did in the early days -- and they pretty much
spread the gospel not only around the country but around the
world) and how it was developed almost entirely to screen for
pre-eclampsia. (Except that there was sort of a sideline of
prenatal care as primarily a social event, getting
pregnant immigrant women together in singing groups, etc. which
seemed at one point to be just as important but got completely
dropped once docs instead of nurses were running the show) The
thing is, as we all know, that treatments for pre-eclampsia were
for the most part pretty horrific -- so how to explain (in
retrospect) the great improvements that getting prenatal care
seemed to show in terms of maternal/infant morbidity/mortality?
I'm hoping, some day, to try to research this stuff more seriously
because a)i find it fascinating but b)it has SO MUCH to do with
what we're doing with prenatal care right now!! It's so hard to
evaluate rigorously the particulars of what we do in prenatal
visits, and you're right -- the studies that have been done don't
show much benefit for any of the above measures -- so what
are you doing during visits now?? Talking and bonding?? and
someone will actually pay for it?? [Very Big Grin]
There is no danger to alkaline urine, it simply means there is
not a lot of acid in her urine. That's it. Usually this is seen
with vegetarians, especially vegans, cause the acids are formed
with animal protein breakdown.
An interesting note about elevated leukocytes. One of my
clients was seeing a nutritionist who told her that insufficient
stomach acid allows larger food molecules into the bloodstream and
that then the immune system has to take over the work of
"digesting" the nutrients in the blood. This causes an
elevated leukocytes reading. Her nutritionist put her on
digestive enzymes, and we'll see if the leukocytes disappear from
her urine! I found some references to digestive
leukocytosis but I can't tell if this is just marketing.
Leukocytes in the urine with repeat negative cultures may be a
sign of interstitial
cystitis, especially when accompanied by protein.
[from ob-gyn-l]
Would be interested to hear input on the use of routine
urinalysis during pregnancy. Seemed pretty useful when you could
simply have the nurse dipstick in the clinic. However, give that
CLIA has pushed the study into the lab and hence inflated the
cost, seems questionable whether to justify the test in
asymptomatic population throughout pregnancy. I'd like to hear
others perspective and their clinical practices.
The latest version of Williams states that unless you are
following a pt for diabetes or hypertension then routine UA's do
not help with the management of a routine pregnancy. We have 4
docs in our Ob dept. and as chair I typically try everything first
(the Mikey syndrome). For the last year I haven't done routine
UA's and pts don't mind trying to hit the cup.
we also do "routine urine dipstix", but with a scaled -down
version; only test for glucose and protein. Testing for leukocytes
is a waste - vaginal contamination is usually responsible for
positive tests. if you are really worried about +leukocytes on
dipstix, repeat test with midstream before requesting lab
analysis.
"Initial care shall be provided as follows:
1.the following tests shall be scheduled or ordered during the
first visit:
a Blood type, including ABO and Rh, with antibody screen,
b urinalysis
c Hematocrit, hemoglobin, or CBC, initially and rechecked at 28-36
weeks.
d syphilis and gonorrhea and chlamydia, unless written refusal for
gonorrhea or chlamydia is obtained from the client.
e rubella titre; and
f One hour blood glucose screening test for diabetes, between 24
to 28 weeks of the pregnancy.
So they can refuse the chlamydia or GC testing. Also may refuse
eye ointment , metabolic screen, IM vit k, but need to attach
written refusal.
Well, I guess none of these tests would hurt anyone, though they would sure get pretty spendy if a client had no insurance.. and a number of them are mostly unnecessary. I would question how many of these are truly needed.
A. Will blood-type change? If she is A-pos then she will always be A-pos
B. Why a urinalysis on a non-symptomatic woman?
C. Hematocrit & Hemoglobin, or CBC --- well, OK, but if a client is really strapped and on WIC, then WIC can do the Hemoglobin.
D. Syphilis Chlamydia, Gonorrhea -- - Sounds like syphilis can't be refused..
E. Rubella titre -- if she has already had rubella or is immunised then what is the point of retesting? It wont change from one pregnancy to the next. (I can see the point of testing postpartum perhaps, to give her the chance to get MMR immunization. Makes more sense...)
F. GGT screen is REQUIRED! Heaven's sakes! One could make a good case that the GGT screen is best used for women with risk factors, and is a waste of time and money for others, and has too many false-positives to be reliable for any worthwhile management decisions.
How agreeable is your board to changes? Can they be persuaded
with evidence (how about a copy of Guide To Effective
Care..[Grin]?)
UA with asymptomatic woman : no point what so ever, but the routine checks for protein at each visit could help diagnose pre-eclampsia.
CBC : again, overkill when anemia status is needed, do a hematocrit
VD : I think the point here is to cure the illness to prevent sequelae to patient and baby
Rubella titer : many women have been immunized by vaccination not exposure to illness and the titer might not protect from disease. Hence, if mom has low rubella titer, keep her away from small kids and exposure to the virus if possible, then inoculate her after pregnancy.
GGT : IMHO, a real crock! Seems as though GD is the illness of
the century. A decade ago, it was barely mentioned and now
everybody must be tested. A better way would be a post prandial
glucose test after lunch. Or a fasting sugar which is high but,
knowing how late our local OBs are with appointments, I wouldn't
want a pregnant lady fasting until noon :-) ! Both of these
alternatives are much cheaper than a tolerance or a carbohydrate
load test.
I'm so glad you brought up the subject of leukocytes in the urine because I was going to do it today. It has become almost ludicrous how many of my women have leukocytes in their urine. Sometimes they have other s/s that lead me to suspect and treat UTI, other times, it's there by itself. Rarely, does it remain a trace. Typically, it becomes "++" on the strip, even if it appears there is no UTI.
Now, I am better than familiar with asymptomatic UTI (AUTI), however, I'm talking about a case where the woman has had a culture and come back negative. Please, if any of you ladies who use these strips have any wisdom, pour it on.
By the way, I'm using 10SG strips.
One suggestion to get more valid results on the test strips........
MAKE CERTAIN THE WOMAN COLLECTS A "CLEAN CATCH" URINE SPECIMEN.
A "clean catch" is a specimen uncontaminated by vaginal secretions or anything which might be on the external tissues.
Leukocytes without nitrites might be a contaminant from the
vagina.
I have also had a rash of these, but in non-pregnant women (many
peri-menopausal). Many of them have been coming in with S/S of
UTI, urine dip + leukocytes, so start ABX presumptively and
cultures come back clean. I don't get it! Saw one today whose
provider (MD) had started her Friday on ABX, still symptomatic,
clean culture, but something she said made me wonder if maybe
giardia? Camping a month ago, diarrhea resolved spontaneously, but
had had suprapubic and bladder pain ever since. Ran it by the
on-call doc, who suggested treating for giardia presumptively,
there's apparently been a lot around here.
I remember reading about it a few years ago, (can't remember
where) and that it was due to increased discharge of pregnancy. I
also have this happen with my pregnant moms. What I do is have
them do a clean catch, even for my dip-stick, and if it doesn't
resolve with that I suggest mild treatment for AUTI, like
increasing fluids, add lemon to their water to aid pH balance and
maybe a few gtt. of uva ursi tincture and check again. If not
resolved then I send them to the lab or a U/A (clean catch of
course) and go from there. Over all I think it is really from the
increased discharge.
For moms w/HepB, once infected, the baby has an 80-90% risk of
becoming a carrier which puts them at higher risk of cirrhosis and
liver CA later in life. This can be prevented by giving HBIg at
birth and vaccinating against Hep B. Minimize exposure by keeping
membranes intact
I had a lady last year with a positive Hep B (actually after
about 4-6 tests she was negative) but I consulted with a doctor
who said we would just need to bring the baby in after birth and
they would test and give the baby the Hep B shot. Of course, if
she has an active case you should transfer care.
I just attended a birth last week to a hep B+ mom. We had to make
arrangements for the baby to get a HBIg shot within 12 hours and
also a HepB vaccination. Home health at the Arkansas Department of
Health took care of this for us. There was no problem with me
being a licensed midwife and attending the birth of a hep B+
woman. I certainly was very careful with universal precautions as
we always should be. But I was EXTRA careful this time. I wore two
pairs of gloves at all times in case I ever needed to pull off a
pair. We made sure no bodily fluids got any place they shouldn't.
And thank God her membranes ruptured while on the toilet and she
bled very little.
Just my two cents worth here since I'm not an expert on this:
Lately, we've had a couple of women turn up with one Hep B screen
positive after several negatives in the OB unit where I work. The
pediatricians in both cases ordered the Heptavax but also HBIg. I
haven't a clue if this is standard operating procedure or not.
I don't think there is any reason for a woman with a history of Hep B to necessarily deliver in hospital. What are the reasons for +HepB? If current IV drug exposure, probably not a great home birth candidate. If occupational exposure, no reason to suspect additional risk. I do think the midwife needs to know if the woman is HepBsAg positive at the time of birth....if so, baby needs to get HBIg immediately following birth, and also start a Heptavax series. Any protocols for home birth of HepBsAg+ moms needs to include appropriate treatment of the neonate.
And of course the midwife will follow universal precautions to
protect herself from infection!
At all the hospitals where I have worked Hepatitis B
Immunoglobulin (HBIg) was given to all babies born to Hepatitis B
surface antigen positive mothers within 2 hours of age along with
the first of the Hepatitis B vaccine series.
My friendly online ped told me that he follows CDC guidelines in taking care of infants of HBsAg positive moms.
Case Management to Prevent Perinatal Hepatitis B (Aug. 15, 1996) NS.-Perinatal transmission of hepatitis B virus is largely preventable -- immunoprophylaxis of exposed infants is about 90 percent effective. Vaccine advisory groups currently recommend screening all pregnant women for hepatitis B surface antigen (HBsAg), treating infants born to HBsAg- positive women with hepatitis B immune globulin at birth, and vaccinating them with hepatitis B vaccine at birth, one month, and six months of age. However, a 1988 survey in New York City found that only 59 percent of eligible infants had received appropriate prophylaxis by 18 months of age.
This article reports a successful case-management program for HBsAg-positive women in Connecticut and evaluates 58 federally funded perinatal hepatitis B prevention programs in the U.S. in 1994. The Connecticut program extended educational outreach to HBsAg-positive pregnant women prior to delivery, notified pediatricians and delivering hospitals about their HBsAg status, and monitored follow-up prophylaxis with a computerized tracking system. The program achieved complete vaccination in 91 percent of enrolled infants, compared with 48 percent of those not enrolled. In other states, less comprehensive approaches without case management produced less impressive results (about 67 percent completion of vaccination).
Comment: This report shows the potential benefit of a comprehensive case-management system, as opposed to single, "silver bullet" interventions, to assure complete immunoprophylaxis. --DM Berwick.
TI.-Prevention of perinatal hepatitis B through enhanced case
management -- Connecticut, 1994-95, and United States, 1994.
SO.-MMWR 1996 Jul 12; 45:584-7.
[from ob-gyn-l]
In a similar vein, how many of you are doing preconception
Varicella titers? How many are recommending vaccination prior to
pregnancy?
In our high-risk clinic and office we ask all patients at initial prenatal visit if they are positive or if their parents know whether they had chickenpox. IF there is no history, we perform a Varicella IgG (about 20% of our patients) . If it is negative, we advise patients on the risks of Varicella and recommend avoidance of infected individuals if possible.
If a patient becomes exposed and has a negative IgG, we recommend Zoster immune globulin (VZIG). If a patient breaks out with a rash anytime after the first trimester, we recommend Zovirax 1g tid (I would look up the recommended dose...Valtrex can be used as an alternative) Varicella pneumonias are treated with antiviral agents even in the first trimester.
Our lab will run a stat Varicella IgG to see if a patient needs VZIG. Still, only under the best circumstances (weekday, patient readily available) can we get results fast enough to decide during the period of effectiveness of VZIG (2-3 days). That is why we screen all patients with a negative history.
I have no experience with routine immunization. I speculate that preconceptional immunization might, at first, be reserved for susceptible patients at high risk of exposure (teachers, health care workers, etc.)
Cost effectiveness? I don't worry, after all, the population will
be rid of most HMO's soon because they will realize those that
don't support research and education are freeloaders.
Prenatal
screening
for toxoplasmosis.
Bader TJ, Macones GA, Asch DA
Obstet Gynecol 1997 Sep;90(3):457-64
Universal maternal screening for congenital toxoplasmosis should not be performed.
Toxoplasmosis
Fact
Sheet from the March of Dimes
In Portugal, Toxoplasmosis titers is part of the standard routine pregnancy control (also rubella, AgHBs, HIV - after consent - and syphilis. It's recommended IgG titers once per trimester and IgM if IgG is positive. But, if you want really control gestational toxoplasmosis, it should be done the first titer before pregnancy and then, once a month, otherwise one can miss the beginning of the infection and so, the right time to start therapy in a way that could have some efficacy in preventing the transmission to the fetus. The parasitemis period occurs during the first month. There are lots of problems with these approach:
But I think that for infections in general, it would be very helpful to have a serum sample stored until the end of pregnancy for every pregnant patients. In the event of fetal conditions in which infections can have a etiologic role, one could test the patient for those infections in an actual sample and a previous one to compare the Immunoglobulin titers. The actual incidence of fetal complications in most of gestational infections is low. Thus, I think that there is more interest in finding an infectious etiology for an abnormality in the fetus that to find an abnormality in the fetus when we have a theoretic possibility of an infection in the mother. Sure, there are exceptions to this rule as in almost all rules (rubella in first trimester is not the same thing). Furthermore, it is still possible to decrease the probability of an infected fetus, in the event of a diagnosis of infection in the mother, if one has available the technical possibility of PUBS. A bunch of tests can be done in fetal blood that, if negative, can decrease more and more that probability. Unfortunately, none of them is 100% accurate.
When IgM for toxoplasmosis is measured by ISAgA, usually, the
curve of the titer rises and then decrease, reaching a plateau
that can stay measurable for years, sometimes with titers
considered high. That plateau phase usually is reach in about 7
months after the acute infection. Thus if, in two simultaneous
measurements of two serum samples taken two weeks apart, there is
the same result it's possible to conclude, with a certain amount
of certainty, that the parasitemia occurred ~7 months before.
Sorry, I have no references for this; I was informed by the
parasitologist of our reference lab in Lisbon.
If we're going to check toxo at all, it should be PRECONCEPTION. If the woman is negative, then she can be counseled to avoid cat litter, undercooked meat and dirt that may be used as a feline toilet. Once she's pregnant, testing causes nothing but headaches.
In a similar vein, how many of you are doing preconception
Varicella titers? How many are recommending vaccination prior to
pregnancy?
After toxoplasmosis, How long should a woman wait before being pregnant ?
A therapeutic abortion was practiced in December 96. IgM are
still positive but IgG are falling.
"Acquired immunity to T.gondii requires time to develop, and the precise time at which it is safe for a woman to conceive after she has been acutely infected has not been clarified. Although relevant data for large numbers of women are not available, congenital transmission has, on rare occasion, been documented in women who have acquired the infection > 1 month before conception. For this reason, it is recommended that a recently infected woman postpone becoming pregnant for at least 6 months".
Extracted from: Wong SY, Remington JS. Toxoplasmosis in
Pregnancy. Clinical Infectious Diseases 1994; 18:853-62.
Toxoplasmosis
- Excellent Patient Education from Kent Midwifery Practice in the
UK (Kay Hardie and Virginia Howes)
Maternal
Thyroid
Deficiency during Pregnancy and Subsequent Neuropsychological
Development of the Child [PubMed
Citation]
James E. Haddow, Glenn E. Palomaki, Walter C. Allan, Josephine R.
Williams, George J. Knight, June Gagnon, Cheryl E. O'Heir, Marvin
L. Mitchell, Rosalie J. Hermos, Susan E. Waisbren, James D. Faix,
Robert Z. Klein
The New England Journal of Medicine -- August 19, 1999 -- Vol.
341, No. 8
Thyroid Disease, Pregnancy and Fertility
Thyroid Disorders and Pregnancy (Thyroid Foundation)
The Facts About Thyroid Problems and Pregnancy (JONES PHARMA INCORPORATED)
Thyroid
Problems and Pregnancy - Headaches, anxiety, nervousness, and
hypertension (EndocrineWeb.com)
Normally in pregnancy, there is an increase in thyroxine-binding globulin which results in increased levels of T4 and T3. The levels of free T4, free T3 and TSH are not affected, while T3 uptake will be normally be reduced.
T4 does not cross the placenta, while T3 does, to some extent. Therefore, if this patient is truly hypothyroid, I would definitely use Armour rather than Synthroid, since it contains a mixture of T3 and T4. (Synthroid is just synthetic T4.)
By monitoring free T4 and TSH, you can safely use Armour thyroid
and adjust the dosage pretty much as you would in a non-pregnant
patient. Just be sure not to rely on T4 or T3 uptake values.
Although it seems unlikely that a low dose of thyroxine would
cause the "hyperthyroid" side effects you observed in this
pregnant patient, it is possible that even a small amount could do
this transiently. Pregnancy itself is a natural "hyperthyroid"
state, i.e., serum thyroxine demands are higher than in the
non-pregnant state. Therefore it is possible that what was
ordinarily a "euthyroid" individual before pregnancy, becomes
slightly hypothyroid during pregnancy owing to the greater demand
on the gland. If carefully followed with frequent TSH
determinations, standard thyroxine should suffice for this person.
Notwithstanding the "curb appeal" of a natural form of thyroid
extract (usually porcine), it is wiser to go with the more
titratable human hormone--with care to avoid cheap generics. You
are correct that it is wise to err on the generous side as a
little too much is safer than too little during gestation.
My comment regarding Armour was in the context of the expressed concern regarding cretinism in the fetus. In general, of course, the fetus produces it's own T4, but this production increases slowly during gestation, normally approaching adult levels only at term. If Armour is used only as true replacement therapy, I would argue that the levels of circulating T3 & T4 are no different than a normal euthyroid patient.
I don't prescribe Armour based on "curb appeal." My clinical
experience is that levothyroxine works better than Armour about
15% of the time, Armour works better than levothyroxine about 50%
of the time, and in the balance of patients, either one produces
satisfactory results. Therefore, my initial therapeutic approach
is usually to use Armour, and to switch if I'm not pleased with
the results.
TB
Blood
Test, Forget TB Skin Tests by Randall Neustaedter OMD - a
great explanation of how the skin test is ineffective and
potentially harmful.
TB TESTS (Mantoux/PPD (Purified Protein Derivative) ) - The Skin Test or Skin Prick Test for TB and information about alternatives!
The package insert claims that "Tubersol is prepared from a large batch Master Batch, Connaught Tuberculin (CT68) and is a cell-free purified protein fraction obtained from a human strain of Mycobacterium tuberculosis grown on a protein-free synthetic medium, and inactivated. Tubersol is a sterile isotonic solution of Tuberculin in phosphate buffered saline containing Tween 80 as a stabilizer. 0.28 percent phenol is added as a preservative." (read more at the webpage)
The 1972 edition of Encyclopedia and Dictionary of Medicine and Nursing defines phenol as "an extremely poisonous antiseptic, germicidal and disinfectant." The Oxford Universal Dictionary (1955) defines phenol as "A hydroxyl derivative of benzene, commonly known as carbolic acid."
QuantiFERON-TB
Test - Blood test as alternative to skin prick test.
Here's some additional
information.
This section has been moved to another
page.
[from ob-gyn-l]
Do you really do an internal, speculum and swabs on every woman
you book in early pregnancy? (We don't here, in fact its the
exception - i.e. if they are symptomatic of infection or are 'due'
for a smear).
In our practice the newly pregnant patients all see the nurse practitioners. Every woman has a pelvic exam complete with PAP (unless one has been done within the past 6 months), cervical evaluation for gonorrhea, chlamydia, and bacterial vaginosis (the method depends upon which laboratory their insurance carrier uses). Also vaginal and rectal swabs for GBS are done at the same time. These evaluations are usually done around the 8-12 th week of pregnancy, but occasionally much later.
Our obstetrical population has a large component of teenage welfare mothers, and we've experienced what we feel to be a significant number of patients with all combinations of these pathogens.
As far as GBS goes, any patients we find with GBS early in pregnancy are treated once, labeled as high risk, then cultured again at 36 weeks and treated in labor if positive. But we've felt that early identification and treatment has definitely prevented some early GBS complications.
Without reculturing everyone at 36 weeks, we realize we may be missing some GBS problems at term. We'll certainly take another look at CDC and ACOG guidelines, but ultimately it will be helpful to know more about why people get GBS colonization in the first place.
In my midwifery training in 1996, we ordered routine postpartum
labwork on all clients. The minimum testing done was a CBC. In my
own practice, I have added TSH and vitamin D and sometimes
hemoglobin A1c, insulin resistance or at least a fasting glucose
if there were any glucose issues during pregnancy.
I thought this was the standard of care, and I know other
midwives who also order postpartum bloodwork as well as a
postpartum Pap smear.
And I'm pretty sure that most OB practices locally also used to
order postpartum bloodwork.
But now it seems that our local OB practices are no longer
ordering postpartum bloodwork, even if the mom was diagnosed with
gestational diabetes. And none of our other local homebirth
midwives order postpartum bloodwork at all.
I find this all a little shocking. Postpartum women are often so tired that it's hard to know whether they're anemic from blood loss at the birth or whether thyroid disease was triggered by the pregnancy.
Central Medical Lab
5552 Cerritos Ave. suite D
Cypress, CA 90630
Smith-Kline labs comes to mind for blood tests and such.
The lab I use is Pathology Labs in Spokane, Washington. They send
you the centrifuge and all the eqipt free.
As long as humans are involved in the testing, human error will be a factor. This applies to cultures as well as to rapid tests. In one of my excursions out on the web I came across a page of notes from a community college course for lab technicians - cultures are fraught with peril and vulnerable to both false negatives and false positives. After reading this, I was even more amazed that practitioners could have a policy that a history of a single positive GBS culture would leave a woman "branded for life" despite a trail of subsequent negative cultures.
I know I have naively assumed that "reputable" labs are 100% reliable. This spring, the large lab I use reported that one of their phlebotomists had been re-using needles to draw blood. Yes, as in using the same needle from one client to the next. It leaves me wondering what kinds of technicians are handling the cultures. I wonder if this is why some protocols have recommended repeat cultures during pregnancy, hoping that if the lab messes up on one of the cultures, at least the repeat is likely to detect a heavy colonization. Maybe this is why they also discount subsequent negatives, figuring that if one of them was false, they're safer assuming it was the negative that was false.
I almost feel more comfortable doing the GBS test myself with a
rapid test that is theoretically less reliable but possibly much
more reliable in practice. If money weren't an issue, I'd
happily use both for clients who want prenatal testing.
This news item l0 June l999 on a local (Vancouver, B.C. Canada) radio station:
Woman Sues St. Paul's VANCOUVER (CKNW/98) -- A Vancouver woman is suing St. Paul's Hospital and several doctors because she was diagnosed as carrying the Aids virus, when in fact she wasn't. In a BC Supreme Court writ, Lisa Lebed claims when she was admitted to the hospital in late 1995 to give birth to a daughter, a blood sample was taken without her consent. It revealed she was HIV positive, so she gave up the baby girl for adoption and decided to have a tubal ligation. A year and-a-half later, while undergoing aids treatment, she found out she was not HIV positive. The explanation she was given was a lab error. She says because of the negligence of the hospital, she's now sterile and has lost a daughter.