Prenatal testing: Beyond Ultrasound

Prenatal testing:  Beyond Ultrasound

Most pregnant women in the United States are subjected to a multitude of tests that may or may not be truly medically necessary.  Always ask “how does this benefit me and my baby?” and “what will be done with this information?” It turns out that common prenatal tests are not necessarily safe, or for that matter, necessary. Many tests introduce additional worry, don’t necessarily improve outcomes, and aren’t particularly accurate.  Educate yourself, schedule an extended appointment with your care provider, ask specific questions, and wait for educated answers. The biggest questions are “What will be done with this information?”  and “Will I, or my baby be healthier because of it?”  Sometimes parents will choose to terminate a pregnancy if the tests are indicative of serious problems.  But many families would not choose this option.  Remember that this is your baby, and the choices are yours.

Ultrasound –

Ultrasonic radiation is used to create an “echo” photo of your baby utero. This is popular and common test that is routinely done is almost all pregnancies in the United States. One problem that is rarely discussed is the research done in the 1980’s that showed manipulation of genetic material in a petri dish.  How this translates to your developing fetus is still under question.

“There are some data (mostly from other vertebrates) suggesting that prolonged and frequent use of fetal ultrasound can cause abnormalities in fetal brain development, behavior, and body weight.[13] Even though such findings have not been substantiated in humans,[13] the US Food and Drug Administration (FDA) considers promotion, selling or leasing of ultrasound equipment for the purpose of making “keepsake fetal videos” an unapproved use of a medical device.[14] Such use may also violate state laws and regulations.” http://www.medscape.com/viewarticle/552964

The fact of the matter is that the use of ultrasound was introduced to obstetrics without any clinical trials.  That means that there were no safety studies done before the technology was introduced.  Each and every woman in the first 20 years of use was a guinea pig, without consent.

A practice 2016 bulletin from the Green Journal states “- – ultrasound energy delivered to the fetus cannot be assumed to be completely innocuous, and the possibility exists that such biological effects may be identified in the future (11). Thus, ultrasonography should be performed only when there is a valid medical indication and, in all cases, the lowest possible ultrasound exposure settings that obtain adequate image quality and gain the necessary diagnostic information should be used, following the as-low-as-reasonably-achievable (ALARA) principle (12).”

All those years of use have given us a body of research that can be used to ascertain safety issues. Certain studies do show an increase in preterm labor, miscarriage, small for gestational age, and left-handedness. Studies published in both the New England Journal of Medicine and the British Medical Journal concluded that “ultrasound screening does not improve perinatal outcome in current US practice.”. That is after all the goal of all testing and interventions – does it improve outcomes?

That said, Ultrasound can be an extremely useful tool when used appropriately.  It can determine if a woman is having twins, or judge the position of a baby (if in question), but is only useful for determining size up to 30 weeks.  After that the information is not particularly useful, as there can be a size discrimination of up to 2 lbs. in either direction.

The key here is to avoid routine use, and restrict this for specific moments when there are concerns or questions that ultrasound can answer. In other words, use it only when medically necessary. So educate yourselves, and make the choice that is right for you and your family.

AFP – The Alpha Fetal Protein test is a blood test commonly done between 14 – 16 weeks.  It may show abnormalities in the pregnancy, or it may just indicate that you are further along than you thought, or that you may be having twins. It just tells you that something is different, but further testing would need to be done to determine what it is.  It is not very accurate, and can often cause great worry for new parents.  Some families choose not to do these tests because they would do nothing different, and don’t want more invasive testing.  Others choose to have it to have it done, and proceed on with other testing.

Amniocentesis – Amniocentesis is a very accurate test that involves the use of large needle, inserted into the amniotic sac. Fluid is withdrawn and tested for certain elements that may indicate anything from Downs Syndrome to Trisomy 18 disorders.  Or it may indicate that your baby is perfectly healthy.  It does require the use of Ultrasound, and has the risk of causing miscarriage.

New Test – MaterniT21 PLUS test

The newest prenatal test is a noninvasive blood test for fetal cell-free DNA (cfDNA). It is used to determine if a baby has Downs Syndrome or other rare, but serious, genetic abnormalities, that may make it incompatible with exterior life, or render it severely retarded. Some parents wish to be as knowledgeable and prepared as possible.

“The MaterniT21 PLUS test, developed and validated by Sequenom CMM, is a laboratory-developed test (LDT) that analyzes circulating cell-free DNA extracted from a maternal blood sample. The test detects the relative amount of 21, 18, 13, X and Y chromosomal material.1,2

A patient with a positive result should be referred for genetic counseling and offered invasive prenatal diagnosis for confirmation of test results.12 Results from this test do not eliminate the possibility that other chromosomal abnormalities may exist in this pregnancy and a negative result does not ensure an unaffected pregnancy. While results of this testing are highly accurate, not all chromosomal abnormalities may be detected due to placental, maternal or fetal mosaicism, or other causes.”

For families who want to have such certainty this is a great advancement, as it has a very low false positive rate, and is not physically invasive. However, it is not infallible, and should be followed up with more extensive testing, such as an amniocentesis.  Since it can be done very early in the pregnancy some families may choose to terminate the pregnancy at that point.  But for parents who would not choose such an option this test would be rather extreme.  The bottom line is always what are you going to do with the information?

Glucose Tolerance test

This is a blood test done around the 24th week of pregnancy to determine if the woman has glucose intolerance. A fasting woman is given a glucose preparation to drink, and then her blood sugar levels are tested at various times.  One of the major problems with glucose tolerance testing is that it does not necessarily tell us if a woman has gestational diabetes. What it can tell us is if her body does not handle excess glucose well (Glucose intolerance) . It can predict if a woman will be at risk for type 2 diabetes  later in life. It may tell us that her diet needs improvement (see chapter 2). But determining if she is actually gestationally diabetic can only be determined by checking her urine for sugar, and doing more extensive testing.

The problem with the standard 1 hour GTT testing is that it can place a woman in the high risk category, when all she really needs is a change in her diet.  It is also expensive to do all this testing, but the attitude is that at least now they will get nutritional counseling. Apparently nutritional counseling is the only actual benefit here. Being labeled high risk then limits a woman’s options for the birth of her baby.  Obstetricians tend to have a cavalier attitude about the label of gestationally diabetic.  They say “oh, we can always induce you or do a cesarean”, without thinking about the additional risks of induction and surgery for both mom and baby.

Why not start with the nutritional counseling, monitor her urine, and dispense with the 1 hr. blood test?  If necessary women can test their blood sugar before and after meals, to judge its stability. As I write, the NIH is holding a conference on this subject, and the overwhelming conclusion seems to be that testing is expensive, and will change the way these women are treated, which will increase the cesarean rate.  Increasing the cesarean rate will increase infant and maternal morbidity and mortality.  In conclusion, this type of testing has not yet proven to improve outcomes, the hallmark of evidenced based medicine. What has been determined to improve outcomes is nutritional counseling.

So what should a woman do? To start with make sure your diet is rock solid. (see chapter 2). The decision to be tested is up to you, not your careprovider.  Woman whose families have a history of diabetes may choose to be tested, but if so you might want to go directly to the 2 or 3 hour test rather than the 1 hour, as they are more accurate.  In the days before you are tested make sure you eat a higher protein, complex carbohydrate diet, and avoid simple carbohydrates, such as sugar and things made from white flour.  (see page ? in chapter 3). If a woman is spilling sugar in her urine it is a sign her diet needs serious improvement, and her blood sugars many need to be tested regularly. But start with prevention – follow the Brewer pregnancy diet.

Group B Strep

Group B Strep  is a bacteria  normal present in the human rectum in small amounts.  Overgrowths in the human body became more common because of poor health, poor hygiene, and the overuse of antibiotics to treat strep A and other bacterial infections.(ear infections in children, strep throat in college students?)  We have created super bugs that are resistant to many of the common antibiotics. Antibiotics also kill the good bacteria in the gut that helps to support the immune system as well.  We end up with yeast problems as well as an imbalance of the PH of the body.  This creates a breeding ground for bacteria.

Testing is done in late pregnancy by swabbing the rectal, vaginal and urethral areas of the pregnant women and seeing if the samples show signs of the presence of group B strep. If it does, then women are treated prophylactically with antibiotics during labor.  Babies exposed to group B Strep during the birth process can become very ill, and develop meningitis, and some have even died. While it sounds like a no brainer to do the testing it is important to note that all tests have pros and cons.  Testing and treating during pregnancy is not helpful, as it does not affect or predict a woman’s GBS status at the time to birth. You can treat, but it can come right back.

Sadly, it seems to be a “damned if you do, damned if you don’t” type of situation.  Contrary to popular practice and protocol, a recent review of the research on GBS from the Cochrane database found that “giving antibiotics is not supported by conclusive evidence. The review identified four trials involving 852 GBS positive women. Three trials, which were around 20 years old, compared ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the occurrence of early GBS infection in the newborn was reduced with antibiotics. The antibiotics ampicillin and penicillin were no different from each other in one trial with 352 GBS positive women. All cases of perinatal GBS infections are unlikely to be prevented even if an effective vaccine is developed.”  They also concluded that   “Ideally the effectiveness of IAP [Intrapartum Antibiotic  Prophylaxis] to reduce neonatal GBS infections should be studied in adequately sized double-blind controlled trials. The opportunity to conduct such trials has likely been lost, as practice guidelines (albeit without good evidence) have been introduced in many jurisdictions.”

On the other hand an analysis of this research published by Lamaze Science and Sensibility concluded that: “In the meantime, women should be aware that other evidence, albeit not from randomized controlled trials, suggests that antibiotic treatment reduces deaths from early onset GBS disease in newborns. According to the Centers for Disease Control and Prevention, a steady decline in GBS disease has been seen in individual institutions, in the whole U.S. population, and in other countries as antibiotic use has risen. But these population-level data cannot tell us whether antibiotics or some other factor caused the decline.

What other advice can we share with women?

  1. 1.     Be aware that antibiotics are not harmless. Severe allergic reactions are possible, and antibiotic use in labor can result in thrush (candida infection) which causes painful breastfeeding and sometimes early weaning. We do not know other possible harmful effects because they have never been studied adequately or at all.
  2. 2.     No study confirms the effect of labor practices on GBS infection in newborns, but here we can use our common sense. Care providers should avoid or minimize sweeping/stripping membranes before labor, breaking the bag of waters, vaginal exams, and other internal procedures, especially those that break the baby’s skin and can be a route for infection. These include internal fetal scalp electrodes for fetal heart rate monitoring and fetal blood sampling.
  3. 3.     Keep mothers and babies skin-to-skin after birth. This exposes the baby to beneficial bacteria on the mother’s skin, facilitates early breastfeeding, and lowers the likelihood that the baby will exhibit signs or symptoms that mimic infection, such as low temperature or low blood sugar, which could cause the need for blood tests or spinal taps to rule out infection.”

Long term prophylactic use of antibiotics has been known in recent medical history to cause the development of antibiotic resistant bacteria, and the potential for an allergy to the particular antibiotic in those who were routinely treated.  Higher rates of  E-Coli infection have been seen in babies  treated with antibiotics for GBS during labor.  This is a dangerous bacterium that is commonly antibiotic resistant, and can kill the baby as well.

It has been recently recommended by the medical community that the use of antibiotics be restricted to treatment of previously diagnosed bacterial infections which are known to respond to such treatment.  Generally, antibiotics should only be used when absolutely necessary. Investigate the option of a Probiotic supplement to support the body and re-establish normal healthy intestinal flora during the use of antibiotics.

An article by Dr. Lewis Mehl-Madrona and Morgaine Mehl-Madrona (Midwifery Today #39, Fall 1996,  p.30 – 32) noted a correlation between exposure to strep bacteria from family members and the development of Postpartum Streptococcal Toxic Shock in mothers.  Perhaps it would be advisable for women who have been exposed to strep throat, for instance by their children, to mention this to their care providers, and ask about testing and treatment.

Many of the “high risk” groups highlighted by the medical professionals are problem groups which we have identified as being potentially preventable through superior diet.  These include: Prematurity, PROM, and possibly fever and infection.  The role of proper nutrition is one that has not yet been investigated with regard to GBS.  However, as with proper hygiene, it is certainly possible that excellent nutrition and regular exercise could boost the immune systems of the pregnant women in question and potentially aid in preventing or fighting infection.  Let’s just say it certainly couldn’t hurt.

People in the US are rather poorly nourished (we may be a wealthy nation, but we eat a lot of processed junk food), and as a result our immune systems are not normal.  Using probiotics, vitamin C, and a good whole food diet helps a great deal. It is important to save the antibiotics for a diagnosed bacterial infection, and then only use the one deemed effective for that particular bacteria.

Ideally a woman should be able to do her best to maintain a healthy body, and prevent overgrowth of bacteria commonly found in the body. Unfortunately the whole scenario has created a “catch 22”.  The US medical establishment is ingrained in treating infections in one way, and has great difficulty departing from that protocol to think holistically.  I would recommend contacting a naturopathic doctor to develop a plan that may help to prevent infection. Look into the option of adding Probiotics to your diet as part of your prevention plan.

Could infection into the vagina possibly occur when a woman wipes from back to front after using the toilet?  Making sure that you are wiping from front to back after using the toilet can help prevent colonization of the rectal bacteria into the vagina. It has even been recommended, by Salee Berman, CNM, that women wash their hands before using the toilet to prevent infection from bacteria that may have been picked up on the hands during the course of the day.  Proper caution with hygiene is a logical practice.  However, research needs to be done to investigate the connection between proper hygiene and GBS infection.

Another important factor that has yet to be addressed is the role that breastfeeding plays in preventing meningitis in infants whose mothers were GBS positive.  We do know that breastmilk (especially colostrum) contains vital antibodies that help to protect the infant against infection.  Is there the possibility that nature has built in a preventative mechanism against infections such as meningitis, and we are not properly utilizing it?  Breastfeeding an infant for the first  6 – 9 months of life is highly recommended by the American Academy of Pediatrics.  On a personal note, I know a woman whose 6 week old infant developed meningitis within a week of being weaned off the breast.   While there is no definitive evidence of a connection between the two, this is an area that needs to be investigated, and soon.

It has long been known that herbs such as Echinacea have antibiotic properties, but Golden Seal should be avoided during pregnancy.  Garlic has a long tradition of use as a natural antibiotic. Another area that needs to be investigated would be the effectiveness of use of these herbs in either treatment or prevention of GBS.  Pregnant women can speak to their care providers and possibly look into speaking to a chartered herbalist who specializes in pregnancy.

Canadian Midwife Gloria Lemay recommends the following for her patients:

“ 1. Boost vitamin C in your diet—e.g., eat 2 grapefruit per day. Other good sources of Vitamin C are red peppers, oranges, kiwi fruit.

2. Drink a cup of echinacea tea or take 2 capsules of echinacea every day.

3. Get extra sleep before midnight. Slow down your schedule.

4. Take 1 tsp colloidal silver per day. Take it between meals. Hold the liquid in your mouth a few minutes before swallowing. Colloidal silver can be purchased in most health food stores. It is silver suspended in water. It is antibiotic in nature and safe in pregnancy if you limit the daily intake to 3 tsps or less. Do not take more because there is a danger of turning your skin permanently blue by overdosing.

5. Plan ahead for extra warmth after the birth for both the mother and baby. Hot water bottles, heating pads, hot packs, big towels dried in a hot dryer during the pushing phase all help keep the mamatoto extra toasty after birth and reduce stress. Have a friend or family member assigned to be in charge of the mother/baby warmth team. Colostrum is the best antibiotic treatment the baby could ever get.

6. Other good prevention tips: Keep vaginal exams to a minimum — 0 is best. Do not allow membrane stripping to start the birth (a.k.a. membrane sweeping). Do not permit artificial rupture of the membranes. Do not allow children of other families to visit the new baby for the first three weeks. Keep the older kids healthy so they are not sneezing and coughing on the new baby.”

And last, but not least, breastfeed your baby for as long as you can. It is the baby’s first vaccination, and best defense system.”

References:

Dekker, R. L. , Diagnosing Gestational Diabetes: The NIH Consensus Conference Day 1; 2013   http://evidencebasedbirth.com/diagnosing-gestational-diabetes-the-nih-consensus-conference-day-1/

Dekker, R. L. , Gestational Diabetes and the Glucola Test, 2012;

http://evidencebasedbirth.com/gestational-diabetes-and-the-glucola-test/ 

Goer, Henci, Obstetric Myths vs. Research Realities;

Gloria Lemay, CPM – Wise woman way of birth – http://wisewomanwayofbirth.com/

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Morgan, S ; Ultrasonic Radiation ; OSHEU Guidance Document NIRP1,  Cardiff University, United Kingdom;  May 2013.

Beech, B.; “Ultrasound: Weighing the Propaganda Against the Facts,” Midwifery Today Issue 51, Eugene Oregon.

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Katz-Rothman, B.; The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood; W. W. Norton & Company; 1993

Field Notes in Obstetrics and Maternal-Fetal Medicine Unnecessary Testing in Obstetrics, Gynecology, and General Medicine: Causes and Consequences of the Unwarranted Use of Costly and Unscientific (Yet Profitable) Screening Modalities Martin Donohoe, MD, FACP. Medscape Ob/Gyn & Women’s Health.  2007; ©2007 Medscape Posted 04/30/2007 http://www.medscape.com/viewarticle/552964

Volkin L, Dargan RS. Study shows potential dangers of ultrasound in fetal development. American Society of Radiologic Technologists 2006 (August 14). Available at: http://www.asrt.org/content/News/IndustryNewsBriefs/Sono/studyshows062408.aspx. Accessed December 28, 2006.

US Food and Drug Administration. Fetal keepsake videos. Center for Devices and Radiological Health 2005 (August). Available at: http://www.fda.gov/cdrh/consumer/fetalvideos.html Accessed December 29, 2006. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm095508.htm

Maternal Blood Test May Detect Trisomy in First Trimester‏. Medscape. Jun 07, 2013. http://www.medscape.com/viewarticle/805519?src=nl_topic&uac=12615PY

(http://www.sequenomcmm.com/home/health-care-professionals/trisomy-21/about-the-test/ )

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Ohlsson A, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD007467. DOI: 10.1002/14651858.CD007467.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007467.pub3/abstract;jsessionid=58DFC5EDED5A6994B2B68BB9F5929AB0.d03t01

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Practice Bulletin No. 175: Ultrasound in Pregnancy;Obstetrics & Gynecology: December 2016 – Volume 128 – Issue 6 – p e241–e256 doi: 10.1097/AOG.0000000000001815; 

[This is an excerpt from a future publication: Haas, AV; Healthy Babies! Healthy Moms! A Practical Guide to Preventing Problems during Pregnancy, Labor, and Birth , 2017]

Avhaas©2017