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Routine Lab Work

Easy Steps to a Safer Pregnancy - View e-book or Download PDF - FREE!
An interactive resource for moms on easy steps they can take to reduce exposure to chemical toxins during pregnancy.

Other excellent resources about avoiding toxins during pregnancy

These are easy to read and understand and are beautifully presented.

See also:

Subsections on this page:

General Information

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

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.

Routine Initial Workup

May, 2000 - The American College of Obstetricians and Gynecologists (ACOG) calls for universal HIV screening of pregnant women

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.)

Urine Tests

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.

Governmentally Mandated Lab Work

"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]?)

Blood Work

IMHO, ABO, rH should only be ordered once if woman continues maternity care with the same provider throughout her reproductive years. Provider needs to know rH factor and it's nice to know if mom is type O because of the possibility of ABO incompatibility after the birth. An antibody screen needs to be ordered with each pregnancy to see if rH sensitization has occurred , regardless of whether mom has received D-Immune globulin (RhoGAM).

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.

Leukocytes in Urine

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........


A "clean catch" is a specimen uncontaminated by vaginal secretions or anything which might be on the external tissues.

  1. Wipe the vulva, front to back with 3 clean moist towelettes. First swipe on one side with 1st towelette (Remind mom to open up the towelette) Second swipe with 2nd fresh towelette on opposite side. Third swipe down the center with 3rd towelette. ALWAYS from front to back. USE THE TOWELETTES FOR ONLY A SINGLE PASS OVER THE TISSUES.
  2. Pee a little into the toilet. Stop the flow and "catch" the rest (or at least some of it) into the container.
  3. If this is a first morning specimen, store the urine in the frig. with a cap on tightly.

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.

Hepatitis B Screening

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.

Chicken Pox/Varicella

[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.

Toxoplasmosis and Varicella

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:

  1. Its cost effectiveness - only justifiable if the incidence of toxoplasmosis in pregnancy is high (I don't know how much is high)
  2. Lots of IgG and IgM titers are false positive, so one has to do a couple of different techniques to screen for those titers. One is not enough. And besides, some techniques for IgM are so sensitive and they can detect so low values that is not anymore truth that a positive IgM means acute infection. Thus, the best way is to redraw blood 2 weeks later and run the tests again and simultaneously in both samples (there are variations among the lot of the kits). But, for that, one should have access to the previous sample and, unfortunately, most labs (at least in Portugal) don't store the serum samples.
About Varicella, if there is risk of exposure, I agree that if, by history, is not possible to confirm a previous infection, then it's worthwhile to have a IgG titer; in the event of an exposure, one should give VZIG to a non-immune patient. If there is no titer before an exposure, there is no time to wait for the result, so we've to give VZIG. However, the embriotoxic effects are very rare and, most of the time is possible to rule out most of the malformations trough ultrasound. The problem is the very small risk of mental retardation without malformations.

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)

Thyroid in Pregnancy

NOTE - Gluten increases the need for synthetic thyroid hormone in those with Hashimoto’s by 49% new study says. [I couldn't find the source!]

One in Six Pregnant Women Tested Are Positive for Hypothyroidism - 15.5% of those tested were positive for gestational hypothyroidism. . . . A growing body of research associates gestational hypothyroidism with a range of medical complications for women and their babies, including miscarriage, pregnancy-induced hypertension, gestational diabetes, low-birth weight and abnormal fetal brain development which may lead to a lower IQ.

Subclinical Hypothyroidism in Pregnancy Usually Transient [12/30/13]

Thyroid Disease in Pregnancy Ups Odds of Complications by Marlene Busko June 06, 2013 [Medscape registration is free.]
This is about untreated hyperthyroidism; treatment with replacement thyroid hormone can prevent the complications.

Screening for Thyroid Disease in Pregnancy Cost-Effective [Medscape, 10/12] - They recommend screening for anti-TPO antibodies and TSH.

Guidelines for Thyroid Disease in Pregnancy: Key Points from Medscape
The new guidelines recommend that before trying to conceive, clinicians should adjust the patient's medication dose with a TSH goal of less than 2.5. Also, patients should increase their thyroid replacement dose by 25%-30% as soon as they miss a period or have a positive home pregnancy test.

New Guidelines Address Hypothyroidism Dangers in Pregnancy [Medscape, 07/11] - Evidence is insufficient to recommend for or against routine screening for antithyroid antibodies among women with miscarriage, or universal TSH screening in the first trimester. However, screening for FT4 level is not recommended.
The Thyroid in Pregnancy by Tricia Westhoff, M.D., and Eli Ipp, M.D.  [Cyberounds registration is free]

Healthy Maternal Thyroid Function For A Healthy Baby by Douglas Husbands, DC, CCN, ABAAHP

Hypothyroidism by Douglas Husbands, DC, CCN, ABAAHP

Hypothyroid Lowers Baby's IQ

Pregnant women with underactive thyroids are four times more likely to have children with low IQs if the disorder is left untreated, a study found.

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.

Celiac Disease

About Celiac Disease

Recurrent miscarriages and/or stillbirths also may represent a symptom of celiac disease, and several researchers recommend screening for celiac in women with these problems. In many cases, following the gluten-free diet after diagnosis enables women to carry their babies to term.

Celiac disease also has been implicated in late first periods in young women, missing menstrual periods (amenorrhea), endometriosis, pelvic pain and early menopause, frequently in women with few or no other celiac symptoms.

The impact of maternal celiac disease on birthweight and preterm birth: a Danish population-based cohort study.  [Free full text]
Khashan AS, Henriksen TB, Mortensen PB, McNamee R, McCarthy FP, Pedersen MG, Kenny LC.
Hum Reprod. 2010 Feb;25(2):528-34. Epub 2009 Nov 24.

CONCLUSION: Untreated maternal CD increases the risk of reduced birthweight, the risk of delivering SGA and VSGA infants and preterm birth. Diagnosis and presumed treatment of maternal CD with a gluten-free diet appeared to result in a birthweight and preterm birth rate similar to those in women without CD.

The University of Maryland Center for Celiac Research recommends a celiac panel including:

tTG-IgA or tissue transglutaminase-IgA
AGA-IgG or Antigliadin IgG
AGA-IgA or Antigliadin IGA
Total IGA

Some labs fail to include one or more of these tests in the panel, so it's useful to check beforehand to make sure it's included.

Quest Diagnostics in northern California offers a

Test Components

   21740 - IGA SERUM

One of the tests, the IGA serum test, is actually not specifically for Celiac Disease, it's to see if a person has a deficiency in IGA, because a small percentage of Celiacs do. And if that is deficient, then it will give a false negative on the other tests that rely on IGA levels for the positive result.

Interpretation of Celiac Disease Blood Test Results
describes exactly what the tests are looking for, that might help:

This link is more than ten years old, however, so there is also a new test out they don't have listed, called a deamidated gluten peptide antibody (DGP) test. I don't know that all insurance will cover it, but it's very specific AND accurate, so it's a pretty good test, I understand. There's a brief bit on it here:

Resurrection of gliadin antibodies in coeliac disease. Deamidated gliadin peptide antibody test provides additional diagnostic benefit.
Kaukinen K, Collin P, Laurila K, Kaartinen T, Partanen J, Mäki M.
Scand J Gastroenterol. 2007 Dec;42(12):1428-33.

CONCLUSIONS: The new gliadin peptide antibody test proved highly accurate in the diagnostic work-up and follow-up of coeliac disease and can be endorsed in combination with the tissue transglutaminase test.

Although this is not yet recommended for universal testing in the US (because of resistance from insurance companies about the cost?), the incidence of celiac disease in women appears to be 1:80.  This means it occurs more frequently than many of the other conditions that are "routinely screened" for in pregnant women.

Some risk factors that can increase the likelihood of celiac disease: Anyone with Celiac Disease already in the family. With a close relative 1 degree removed, a woman's chances of having celiac disease are 1 in 22. With a more distant relative like cousins, aunts, and uncles, chances are 1 in 56.

Auto-immune diseases in the family, or in the pregnant woman, increase the risk for having this disease, as well, especially hypo or hyper thyroid issues or diabetes, although I imagine diabetics are too high risk for at-home midwives.

One issue during pregnancy that might be suggestive of Celiac Disease is vitamin deficiencies in pregnancy that aren't responding to supplements. Some women reported losing weight continually rather than gaining, or gaining weight too slowly, especially if they are eating sufficiently. Something else that women have reported is hyperemesis or severe nausea and vomiting for most or all of the pregnancy, if they managed to carry a previous pregnancy to term. And an odd issue is a strange, persistent taste in the mouth no matter what is eaten, frequently a sour taste, but not acid reflux or heartburn related. - Shauna


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.

New Tests for Latent TB May Be Unreliable in Pregnancy [Medscape,

Interferon Gamma Release Assay Compared With the Tuberculin Skin Test for Latent Tuberculosis Detection in Pregnancy.
Worjoloh A, Kato-Maeda M, Osmond D, Freyre R, Aziz N, Cohan D.
Obstet Gynecol. 2011 Dec;118(6):1363-1370.

CONCLUSION: Comparing the tuberculin skin test and interferon gamma release assay results in pregnancy, concordance and agreement were poor. Given that much is still unknown about the performance of interferon gamma release assays in pregnancy, further research is necessary before the tuberculin skin test is abandoned for screening of latent TB infection in pregnancy.

[Ed: It appears that the concern is about false negatives from the blood test.]

Prenatal Vaginal Exams

This section has been moved to another page.

Routine Cultures

[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.

Where to get Lab Work Done

Lab for Pap Smears

have a good one, only $5.90 for each test

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.

Lab Errors

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.


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