New Patient, OB Packet

Patient Name *
Date of Birth *

Month Day Year
Date
Congratulations on your pregnancy!
We are excited to be providing your Obstetrical care at Alliance ObGyn. Please review the following information on recommended testing. Additional information on each test is provided in the links below. Your testing selections should be completed prior to your Nurse Intake visit around 8 weeks.

You will see your doctor or midwife at your 12 week appointment. This is the first opportunity to listen to the heartbeat by Doppler.

If you are experiencing any issues prior to your appointments, please call our office at 517-484-3000. Please be aware that any appointments related to your pregnancy prior to your Nurse Intake visit may be billed as a separate office visit and may not be included in your routine OB care.

Please note your insurance may not cover all of these options. It is the patient's responsibility to understand their insurance coverage.
Covid-19 Vaccine Information
Have you received the Covid-19 vaccine? *

Yes No
Please enter the date of your first vaccine.

Month Day Year
Date
Please enter the date of your second vaccine (if applicable).

Month Day Year
Date
Which vaccine did you receive? *

Pfizer Moderna Johnson & Johnson I have not received the vaccine.
OB Screening and Testing Information
First Trimester Dating Ultrasound: We recommend an Early Ultrasound around 8-9 weeks of pregnancy to confirmdue date and how many babies are growing. This ultrasound will be scheduled as a seperate appointment after your RN Intake visit.
This is a screening ultrasound and in the event it, or any other ultrasounds, are not covered by your insurance, you will be responsible for any fees for these services.
*

I consent to first trimester dating ultrasound. I decline a first trimester dating ultrasound.
Maternal Genetic Carrier Screening: We recommend screening for genetic issues that may be passed down in pregnancy. This involves a blood test for the pregnant woman to see if she is a "carrier" for specific issues. Please review the following: Cystic Fibrosis Carrier Screening, Hemoglobinopathies Screening, and Spinal Muscular Atrophy (SMA) Carrier Screening. If you already know your carrier status, you do not need to be retested. Some women with specific risk factors may be offered maternal genetic screening for Fragile X Syndrome Carrier Screening and Ashkenazi Jewish Ancestry Carrier Screening.
*

I consent to carrier screening for Cystic Fibrosis, Hemoglobinopathies and Muscular Dystrophy. I decline maternal genetic carrier screening OR already know my carrier status.
Fetal Genetic Screening: We recommend genetic screening for the fetus in addition to the 20 week anatomy ultrasound of the baby. This is a blood draw for you and does not pose any risk to the baby. Please review the Fetal Genetic Screening Information and Codes.
*

I would like a Nuchal Translucency Ultrasound, Free Cell DNA Test and AFP Test. I decline additional genetic testing.
Disease Screening: The Physicians and Midwives at Alliance Obstetrics & Gynecology in addition to The American College of Obstetricians and Gynecologists (ACOG) and the Michigan Department of Health and Human Services (MDHHS) recommend that all pregnant women undergo testing for HIV, Syphilis, Hepatitis B, Hepatitis C, Urine Drug Screen, Gonorrhea and Chlamydia. This is universal testing and not based on risk factors. If you don't do these tests during pregnancy, your pediatrician will recommend additional screening and treatments for your newborn.
*

I agree to recommended screenings. I decline the recommended screenings.
Please answer the following questions about your personal history as well as your family history.

Pregnancy History Form

Do you or the baby’s father have a personal or family history of *

	Yes	No
Spina Bifida (open spine)
Hemophilia
Muscular Dystrophy
Cystic Fibrosis
Blood clots
Sickle cell anemia or carrier status
Ashkenazi Jewish Ancestry
Two or more miscarriages
Congenital heart defect
Mental Impairment
Other genetic or chromosomal issue

*If yes, please provide details:
Mother's Race *

Asian Native Hawaiian Other Pacific Islander Black/African American White Unreported/Refuse to Report
Mother's Ethnicity *

Hispanic or Latino Not Hispanic or Latino Refused to report
Race and ethnicity of the father of the baby:

Please complete the following table about your PERSONAL pregnancy history.

	Miscarriage, termination, or type of delivery	Weeks gestation at delivery/end of pregnancy	Infant’s Birth Weight	Complications (with pregnancy or delivery)	Place of delivery/delivering physician	Gender	Name
First pregnancy
Second pregnancy
Third pregnancy
Fourth pregnancy
Fifth pregnancy
Sixth pregnancy

In the past year, how often have you used the following: *

	Never	Once or twice	Monthly	Weekly	Daily or almost daily
Alcohol, 4 or more drinks per day
Tobacco products
Prescription drugs for non-medical reasons
Illegal Drugs

Treatment and Testing During Pregnancy
During your pregnancy, you will be scheduled for routine visits with providers at Alliance OB/GYN. These appointments allow your provider to monitor the health of you and your baby. They also allow your provider to screen for potential complications that may occur in pregnancy, and intervene as early as possible to ensure the best possible outcome for you and your baby.

Additional tests in the form of blood work, ultrasounds, and/or fetal monitoring may be ordered based on your personal history or the way your pregnancy is progressing. Your provider will discuss the purpose of these tests with you in detail and will answer any questions that you may have.

If you are unable to come in for your scheduled appointment for any reason, we encourage you to reschedule as soon as possible. If you do not want to keep your recommended appointments for either routine visits or testing, you will be encouraged to schedule an appointment to discuss your decision with your provider.

All appointments and tests are to promote the healthiest outcome for you and your baby. Failure to keep any appointments, including ultrasound or monitoring, may seriously jeopardize your health and your baby’s health. This may lead to increased illness or even death of you or your baby.
Signature *

Clear
Pregnancy Care Options: We offer three pathways for your OB care: Traditional, Midwife and Centering**. If you are a low risk pregnancy, you may consider choosing the Midwife, Centering Pregnancy or Traditional Care option. High risk women will need to do Traditional Care option with an OB/GYN. Please review our FAQ about Midwifery Care and our FAQ about Centering Care before your Intake Visit.
**Centering option is currently not available due to COVID-19.
Delivery at Sparrow Hospital: We have multiple Alliance Physicians and Alliance Midwives covering Sparrow Hospital to provide care during your delivery and hospital stay. You can learn more about each of us on our website under the Providers page. Although we cannot predict which Alliance provider will be on call the day of your delivery, we do know that you will get exceptional care. We have an Alliance Birth Partnership that reviews our standard of care for delivery.
How to Contact Us: If you have a non-urgent medical question that cannot wait until your next appointment, please contact our nurses through your Follow My Health Allianca patient portal. We are also available by phone for urgent medical issues. The operator will send your information to the nurses and you will receive a phone call back. For emergent issues, head directly to the hospital.
Common Questions:
Financial Documents:
- Patient Financial Policy
- Insurance Codes for Genetic Screening
Patient Demographic Information
Patient's last name: *
First: *
Middle:
Preferred to be called:
Is this your legal name? *

Yes No
If not, what is your legal name?
(Former name):
Marital Status *

Single Married Divorced
Birth date: *

Month Day Year
Date
Age: *
Sex: *

Male Female
Street Address: *
P.O. Box / Apt #:
City: *
State: *
Zip Code: *
Cell Phone:
Home Phone:
Social Security Number:
Email Address:
Employer:
Employer Phone:
Race *

Asian Native Hawaiian Other Pacific Islander Black/African American White Unreported/Refuse to Report More than one race
Ethnicity *

Hispanic or Latino Not Hispanic or Latino Refused to report
Language:
Preferred Notification Method: *

Phone Postal Mail Portal
Family Physician First Name: *
Family Physician Last Name: *
Family Physician Phone:
Referring Physician First Name:
Referring Physician Last Name:
Referring Physician Practice:
Referring Physician Phone:
Insurance Information
Upload pictures of the front and back of your insurance card.

Browse Files
You can select multiple files Cancel of
PRIMARY INSURANCE: *
Subscriber's Name: *
Subscriber's Date of Birth: *

Month Day Year
Date
Patient relationship to subscriber: *
If patient is a minor, Name of Guarantor
If patient is a minor, Guarantor's Date of Birth

Month Day Year
Date
Enrollee, Subscriber or Policy ID # *
Subscriber's Employer: *
SECONDARY INSURANCE:
Secondary Insurance Subscriber's Date of Birth:

Month Day Year
Date
Secondary Insurance Patient relationship to subscriber:
Secondary Insurance Subscriber's Name:
Secondary Insurance Enrollee, Subscriber or Policy ID #
Secondary Insurance Subscriber's Employer:
Emergency Contact
Name of local friend or relative: *
Relationship to patient: *
Cell Phone:
Home Phone:
Work Phone:
I hereby authorize the release of any medical information necessary to process my insurance claim. I authorize payment to be made directly to Alliance Obstetric and Gynecology, TIN #38-3381725. I have been provided with a copy of the Alliance Financial Policy and understand that I am financially responsible for any balance not covered by my insurance carrier.

Please review the Alliance Patient Financial Policy.
Name *

First Name Last Name
Signature *

Clear
Medical History
Please check all that apply to you.
Breast

Breast Lump (benign) Breast Cancer Fibrocystic Disease of the breast Cyst of the Breast Nipple discharge Mastitis Breast Infection
Cancer

Brain Cancer Cervical Cancer Colon Cancer Lung Cancer Ovarian Cancer Rectal Cancer Skin Cancer* Stomach Cancer Thyroid Cancer Uterine Cancer Other Cancer**
*Type:
**Type:
Cardiovascular

Blood Clot Heart Disease Hypertension Hypercholesterolemia Peripheral Vascular Disease Pulmonary Embolism Raynaud's Syndrome Rheumatic Heart Disease Heart Problem*
*Type:
Dermatological

Acne Ulcer of the skin Lupus
Endocrine

Goiter Graves' Disease Hashimoto Thyroiditis Hypothyroidism Partial Thyroidectomy Full Thyroidectomy Gestational Diabetes Insulin Dependent Diabetes Non-Insulin Dependent Diabetes Polycystic Ovarian Disease
Gastrointestinal

Cholelithiasis Crohn's Disease Diverticulitis of the colon Cirrhosis of Liver Gastric Ulcer Irritable Bowel Syndrome (IBS) Ulcerative Colitis Acure Hepatitis Viral Hepatitis A Viral Hepatitis B Viral Hepatitis C Hemorrhoids
Genitourinary

Endometriosis Infertility Ovarian Cyst Kidney Disease Chronic Cystitis Kidney Stones Gonorrhea Chlamydia Lichen Sclerosis Premenstrual Dysthymic Disease History of Abnormal Pap* Interstitial Cystitis Pelvic Inflammatory Disease (PID) Genital Warts Herpes-Genital
*Type:
Menstrual History

Bleeding or spotting between periods
Last menstrual period: *
How heavy is your flow during periods? *

Light Moderate Heavy

Please answer the following questions: *

	Yes	No
Do you have clotting during your periods?
Do you have painful cramping during your periods?

HEENT

Deafness Blindness Glaucoma Migraine with aura Migraine w/o aura
Hematological

Anemia Sickle Cell Anemia DVT/Pulmonary Embolism Hemophilia Von Willebrand's Disease Thrombophilia or clotting disorder
Musculoskeletal

Arthritis Fibromyalgia Osteopenia Osteoporosis
Neurological

Migraine Migraine with aura Multiple Sclerosis Parkinson's Disease Myasthenia Graves Stroke Seizure Disorder
Psychiatric

Alcohol Abuse Anorexia Nervosa Anxiety Disorder Depression OCD Schizophrenia Suicide Attempt Post-Partum Depression Bulimia Nervosa Borderline Personality Disorder
Respiratory

Asthma COPD Sleep Apnea
Surgical History
Have you ever had any surgeries? *

Yes No

List the year for ALL procedures that apply to you. List ALL OTHER surgeries at the bottom.

	Year(s)
D&C
Ovarian Surgery *give details below
Hysteroscopy Removal of Polyp
Hysteroscopy Removal of Fibroid
Laparoscopy
Myomectomy
Infertility Surgery
Vulvar Surgery **give details below
Hysterectomy - Vaginal †give details below
Hysterectomy - Abdominal ‡give details below
Cesarean Section
Tubal Ligation (tubes tied)
Vaginal or Bladder Repaid for Prolapse or Incontinence
Endometrial Ablation

Other surgery, type & date
Other surgery, type & date
Other surgery, type & date
*Type of Ovarian Surgery:
**Type of Vulvar Surgery:
†If yes, do you:

Still have cervix Still have both ovaries Still have one ovary
‡If yes, do you:

Still have cervix Still have both ovaries Still have one ovary
Allergies to Medications
Do you have allergies to medications? *

NO, I do not have allergies to medications YES, I have allergies to medications as listed below
List the medications to which you are allergic, followed by your reaction to those medications:

Other Allergies: *

	Yes	No
Iodine Allergy
Latex Allergy

Current Daily Medications, Vitamins, Over the Counter Supplements and Medical Devices

Please fill out the following table:

	Medication	Dose (amount)	Frequency (how often taken)
1
2
3
4
5
6
7
8
9
10

Family History

Indicate which, if any, family members have had the following conditions:

	Mother	Father	Brother	Sister	Son	Daughter	Maternal Grandma	Maternal Grandpa	Paternal Grandma	Paternal Grandpa
Diabetes - Insulin Dependent
Diabetes - Non-Insulin Dependent
Heart Disease
Breast Cancer
Ovarian Cancer
Uterine Cancer
Colon Cancer
Blood clots (leg/lungs)
Thrombophilia
Stroke
Hypertension

Social / Sexual History
Do you have a history of abuse? *

Yes No
Are you currently being abused? *

Yes No
History of abuse: Check all that apply. *

Physical Mental Verbal None
Are you currently using tobacco (chewing or smoking)? *

Yes No
Tobacco: Amount
Tobacco: How frequently?
Are you exposed to second hand smoke? *

Yes No
Second Hand Smoke Exposure: How frequently?
Second Hand Smoke Exposure: Type
Are you currently using alcohol? *

Yes No
Alcohol: How frequently?
Alcohol: Amount
Are you currently using illicit drugs? *

Yes No
Illicit Drugs: Type
Illicit Drugs: Amount
Are you currently using birth control? *

Yes No
Birth Control: Type (i.e. IUD, pills, condom, etc)
Are you currently exercising? *

Yes No
Exercise: How often?
Exercise: Type
Marital Status: *
Living Situation: *
Occupation: *

Additional questions: *

	Yes	No
Are there religious beliefs affecting medical care?
Are you agreeable to receiving blood/blood products?

Please answer the following questions: *

	Yes	No
Do you wear a helmet?
Do you wear a seat belt?

Have you ever been sexually active? *

Yes No
Are you currently sexually active? *

Yes No
Number of sexual partners currently: *
Please indicate, are you sexually active with: *

Male Female Both Decline
Please specify any other relevant information:
History of Pregnancy
If you have never been pregnant, please enter 0 in those fields.

Please list your total number of: *

	Number
Pregnancies
Deliveries
Pre-Term Deliveries
C-Sections
Miscarriages
Abortions
Live Births
Ectopic Pregnancy

Have you had any of the following during pregnancy:

Gestational Diabetes Preeclampsia Multiple Gestation Twins Multiple Gestation Triplets Fetal Demise Placental Abruption Hemorrhage Pre-Term Labor
Immunizations

Indicate the date of your last immunization. If you are unaware of the date or have not had, please indicate with N/A. *

	Date
Tetanus Shot
MMR Shot (measles)
Flu Shot
Pneumonia Shot
Shingles Shot
Varicella (chicken pox) Shot
Gardasil (cervical cancer) Shot

Health Maintenance

Please fill out the following table: *

	Date	Result	N/A
Last Mammogram
Last Colonoscopy
Last Bone Density
Last Pap
Last HPV

If you've ever had an abnormal pap, in what year?
If you've ever had treatment for an abnormal pap smear, what type of treatment have you had?

Have you ever had treatment for any of the following?

	Year
Cryotherapy
Laser
Cone Biopsy
Loop excision (LEEP)

Have you had a BRCA screening (blood test for breast cancer gene)? *

Yes No
Do you need assistance with your visit? (i.e. wheelchair, interpreter service, etc):

Congratulations!

Congratulations on your pregnancy! We encourage you to begin taking an over the counter prenatal vitamin that is high in folic acid.

At your first appointment you will meet with a Registered Nurse to review your medical history, discuss diet, activity and answer questions. The appointment will take approximately one hour.

In this packet you will find all forms that must be completed prior to arriving. You must arrive 30 minutes prior to your appointment time to allow for registration and medical record updates based on your history forms.

The following is a list of items you will need to have completed and/or bring with you to your appointment.
- Patient Information - included in this packet
- Medical History - included in this packet
- Prenatal Testing Information - included in this packet
- Valid Picture ID (Driver's License or State ID)
- Insurance Card(s)
- Any previous OB/GYN medical records
PLEASE BE AWARE THAT RESCHEDULING WILL BE NECESSARY IF ANY PORTION OF THIS FORM IS INCOMPLETE AND/OR FAILURE TO ARRIVE 30 MINUTES PRIOR TO APPOINTMENT TIME.
Alliance is excited to offer a new way to get pregnancy care. CenteringPregnancy is prenatal care that includes traditional health check-up with additional time and attention in a group setting facilitated by a Nurse Practitioner or Nurse Midwife. Please be sure to read the information in this packet and review the prezi presentation on our website.
At the conclusion of the prenatal interview, we will arrange for your prenatal lab work to be done at a local laboratory. Our receptionist will then schedule an appointment with your physician for your prenatal physical if you have not already done so. Prior to your office visit, please check with your insurance company to see if an authorization is required for maternity related services. If you are unable to keep this appointment please notify our office 24 hours prior to your appointment. If you do not cancel your appointment in the designated time we may be unable to reschedule your appointment.

Thank you for choosing Alliance Obstetrics and Gynecology, PLLC for your health care.

Prenatal Information

DELIVERING PHYSICIAN
Our call rotation is evenly split and you will be delivered by the physician on call. Our on call doctor is not scheduled to see patients in the office, allowing them to be more available to laboring patients.

PATIENT QUESTIONS
At your first visit the nurse will review our website which is an excellent resource for pregnancy related questions. If the information included in your packet fails to answer your questions, and you are unable to wait until your next appointment, please call our phone nurses. When you call the office our operator will pass the information to the nurses. Calls are returned between the hours of 9am and 4pm. Be sure to give a number where you can be reached all day. In addition, the patient portal is a great way to communicate non-urgent questions to our nurses. If you have not signed up for our portal, please ask your nurse at your first visit.

THINGS TO AVOID

Cigarettes, alcohol, “street” drugs, caffeine, saccharin
Vaginal douching
Over the counter drugs, not listed on the “Common Problems & Medication” sheet
Old prescription drugs, prescribed prior to being pregnant
Hot tubs, Jacuzzis and whirlpools with water exceeding 100 degrees Fahrenheit
Toxic substances, i.e. varnish, paint remover, etc. Use only with good ventilation for short periods of time.
Avoid intercourse if threatening to miscarry, experiencing bleeding/cramping, if your bag of water has ruptured or if you feel you may be in premature labor.
If you are a cat owner, refrain from emptying the cat litter box. Wear gloves while working in the yard or garden.

ISSUES OF CONCERN
If you experience any of the following please call our office, Monday – Friday, 8:00 a.m. to 4:30 p.m. If you experience the following after our regular clinic hours, please go to OB admitting at Sparrow Hospital, 3rd floor.

Chills or fever over 101 degrees Fahrenheit
Painful or burning urination
Bloody discharge or bright red bleeding from the vagina
Persistent abdominal pain that is not relieved by a bowel movement
Severe nausea or vomiting/diarrhea that could lead to dehydration. (Severe meaning several times within an hour)
Visual disturbances, i.e. blurring or doubling of vision
Severe or persistent headache lasting more than 2-3 hours after taking regular or extra strength Tylenol as directed by package
Before 36 weeks if you think you are in labor. Go to Sparrow early, as we may need to try to stop preterm labor conditions.
After 36 weeks – as long as the baby is active and water is not broken, stay home as long as you are comfortable. When contractions are strong and regular, go to Sparrow.
Gush or steady leaking of fluid from vagina, even if you are not having contractions.

It is not necessary to call us before you go to Sparrow, they will notify us of your arrival.

NUTRITION, HYDRATION AND WEIGHT GAIN
We DO NOT want you to diet while you are pregnant. We encourage you to read the information in your packet regarding what you can and cannot eat. This will provide you with good information on healthy eating while pregnant. We encourage a minimum of six to eight glasses of water daily. A weight gain of 20-40 pounds during your pregnancy is recommended, depending on your build.

EXERCISE GUIDELINES

Do not become over fatigued while exercising
Do not put yourself at risk for injury, or risk of falling and possible injury to the baby
Keep heart rate under 140
Any other questions regarding exercise or other activities, please ask your doctor.

GENERAL PLAN OF CARE
An average pregnancy lasts 40 weeks and the following is a general plan of care. Below is a generalized appointment list. There may be changes to the schedule below due to individual needs and as directed by your physician

At each visit you can anticipate: Weight, Blood Pressure, Urine dip (to check for protein & sugar), Measurement of uterus and Baby’s heartbeat (after 10 weeks) via Doppler.

TRADITIONAL CARE
Your visits will be organized to reflect our “modified group practice”. One of our physicians will be your primary obstetrician. This means you will see him/her for the majority of your visits, especially in the first 20 weeks and last 4 weeks where decisions are to be made and complications occur more frequently. The middle months are usually uneventful, and are used to visit each one of the other physician’s so you can get to know all of us. You also have the option of scheduling all of your appointments with your primary physician. If you choose to only schedule with your primary there are a couple things we need to bring to your attention; one of the other physicians may be on call when you deliver and when you reach 36-40 weeks and are seen on a weekly basis, your physician may be out of the office and you would be required to see another physician.

CENTERING PREGNANCY CARE
This is a new way to get prenatal care in a group setting facilitated by a Nurse Practitioner or Nurse Midwife. Each group consists of 8-12 women with similar due dates and meets for 10 2-hour sessions during your pregnancy. These group schedules are set in advance for your entire pregnancy allowing you to plan ahead and have little risk of changing. Groups include discussion, activities and time for sharing in a relaxed and fun setting. In this model you will also have a few traditional visits with your primary physician.

COMPARISON CENTERING VS. TRADITIONAL
Here is a comparison of what your appointment schedule would be like in the CenteringPregnancy model vs. Traditional model. This may be helpful for you to determine which option works best for you.

CenteringPregnancy	Traditional
7-9 weeks – RN Visit History review Education Lab work	7-9 weeks – RN Visit History review Education Lab work
10-12 weeks – Exam with Usual Provider Physical Exam History review Listen to baby’s heartbeat (using Doppler) 10 weeks or more	10-12 weeks – Exam with Usual Provider Physical Exam History review Listen to baby’s heartbeat (using Doppler) 10 weeks or more
12-16 weeks – Session 1 Group	14-16 weeks – Visit with Nurse Practitioner
18-20 weeks – Ultrasound & Usual Provider Visit An ultrasound of the baby’s anatomy	18-20 weeks – Ultrasound & Usual Provider Visit An ultrasound of the baby’s anatomy
16-20 weeks – Session 2 Group	24 week – Visit with Physician
20-24 weeks – Session 3 Group	28 week – Visit with Physician Lab work
24-28 weeks – Session 4 Group Lab work	32 week – Visit with Nurse Practitioner Discuss labor, baby care and postpartum planning
26-30 weeks – Session 5 Group	34 week – Visit with Physician
28-32 weeks – Session 6 Group Group B Strep culture	36 week – Visit with Usual Provider Group B Strep culture
30-34 weeks – Session 7 Group	37 week – Visit with Physician
32-36 weeks – Session 8 Group	38 week – Visit with Physician
34-38 weeks – Session 9 Group	39 week - Visit with Physician
37-39 weeks – Visit with physician**	40 weeks 1 day – Visit with physician Non-stress Test with MA Ultrasound – with Ultrasound Tech
36-40 weeks – Session 10 Group
40 weeks 1 day – Visit with physician Non-stress Test with MA Ultrasound – with Ultrasound Tech	Labor & Delivery Class – 2 sessions* Natural Child Birth Class – 4 sessions* Held at Expectant Parent Organization*

*This is an optional service with an additional cost and is not provided at Alliance.
**Group session and traditional visits to equal once a week between 36 weeks and 40 weeks gestational age.

Should I have Prenatal Testing done?
Although most babies are born in great condition, worrying that your baby may have a problem is common in pregnancy. A variety of tests are available to help detect some of these problems. This worksheet will help you decide if you want any testing done, and if so, what type is right for you. Please review this information and answer the questions at the end BEFORE your first visit with the nurse, and bring it with you so we can help make a plan for your pregnancy.

Prenatal tests are used to screen for problems such as chromosome abnormalities (for example Down or Edwards Syndrome), or open neural tube defects (for example spina bifida or anencephaly). Test types fall into two categories: screening tests and diagnostic tests. They can be performed in the first trimester at 10-13 weeks, the second trimester at 15-20 weeks, or in both trimesters. Different types of testing are recommended based on each mother’s individual risk.

Screening tests do not tell you if your baby has a problem, they only tell you if you are above or below the average risk for them. The advantage of screening tests is that they pose little to no risk to you or your baby. The disadvantage is that they don’t give you a definitive answer, and they have “false positives” (abnormal test, normal baby) and “false negatives” (normal test, abnormal baby). The chance that an affected baby will have an abnormal screening test (abnormal test, abnormal baby) is called the “detection rate”.

Diagnostic tests are very accurate and will almost always give you definitive yes or no answer. Diagnostic tests are nice because you usually know for sure what’s happening, but they carry small risks, sometimes causing miscarriage of a normal baby. So the result of a diagnostic test is more definite than one you get with a screening test, but the risk is slightly higher too. These types of tests are generally recommended if you have an abnormal screening test.

Fetal Anatomy Ultrasound
As a part of your routine prenatal care, your doctor will order a fetal anatomy ultrasound between 18-20 weeks. This ultrasound will be ordered regardless of your decision to have prenatal genetic screening or diagnostic testing.

What is it?
This ultrasound is one of the best ways to see how your baby is developing and offer some reassurance that at this point in pregnancy the baby is developing normally. This is a screening ultrasound, not a diagnostic test. An anatomic Ultrasound will evaluate your baby’s growth and major organs, to be sure they have formed properly. It is a special test that gives you a specific glimpse of your growing baby. This test does not check your baby’s chromosomes. A prenatal anatomic ultrasound does not detect all physical abnormalities of a baby. During your ultrasound, the baby will be measured from side to side on his/her head, around the head, around the abdomen, and from hip to knee (femur bone). And that's just for starters. The four chambers and blood vessels of the heart will be evaluated, as well as the stomach, kidneys, and bladder of your baby. The internal structures of the baby's brain will be evaluated along with the spine, arms, legs, face and profile. A survey of the baby's anatomy, as well as the placenta location, amniotic fluid levels, and umbilical cord, will help to ensure that the pregnancy is overall developing normally. But if not, it may identify potential problems and thus lead to creating the best possible care plan for you and your baby. The ultrasound will give your doctor a picture of the overall health of your baby and your pregnancy. If you would like to find out the gender of your baby, that too is possible at this time.

What does the mother expect during the ultrasound?
You will lie back on an exam table with your belly exposed, and a sonographer will apply a special gel and move the transducer over your abdomen. As sound waves are emitted from the transducer, they will bounce off "structures" inside your belly and images are formed on the screen. To get the most information from the anatomy of your baby, the sonographer will be obtaining many different views from a lot of different angles. When the sonographer obtains a clear picture, she will freeze-frame the picture for the doctor. The ultrasound can take anywhere from 20 to 50 minutes, depending upon how cooperative your little one wants to be. All electronic devices (including cell phones) must be turned off during the appointment. We don’t allow any pictures or recording of the exam, but you can expect to go home with a couple of pictures as well as a CD. The doctor will review the results of the exam following your ultrasound once the sonographer has obtained all of the images and measurements needed.

Screening Blood Tests
Full Integrated Test
This test combines results from two sets of tests, a blood test and ultrasound done at 11-13 weeks, and another blood test done at 15-18 weeks. The results of the ultrasound and both blood tests are analyzed together after the second blood draw. This test screens for Down Syndrome (Trisomy 21), Trisomy 18, and open neural tube defects such (spina bifida for example). This test detects 94% of fetal Down Syndrome, and has a low false positive rate (5%). Results are available by about 16-19 weeks (after your second blood draw). The results will provide you a personalized risk number for each tested condition. For example: Down Syndrome risk is 1 in 1100. Because of its low false positive rate, this test is recommended for patients who are low risk but wish to have more information than that which is provided at the 20 week ultrasound.

Noninvasive prenatal test
A noninvasive prenatal test (NIPT) is a single blood test performed any time at or after 10 weeks. During pregnancy, 3-13% of the DNA in your blood stream is circulating cell free fetal DNA that comes from the placental cells. A NIPT works by evaluating the amount of cell free DNA in your blood. NIPTs screen for Down Syndrome (Trisomy 21), Trisomy 18, and Trisomy 13. This screening test is recommended for patients who are considered to be high risk for fetal chromosome abnormalities. Detection rate for Down Syndrome is reported at 99% in high risk women (those who are age 35+, who have a history of a previous child with a chromosomal abnormality, or those with Robertsonian translocation). Cell free DNA screen does not evaluate the risk of open neural tube defects or any other abnormalities that may be present. This testing is not recommended for low risk patients due to an increased likelihood of false positive results.

Alpha-Fetoprotein test
This test is a single blood test done around 15-22 weeks and assesses only the risk for fetal open neural tube defects. This test may be recommended for high-risk patients who are also having a non-invasive prenatal test.

Look over this table for more information about the pros and cons of each of the above screening tests.

Test	What it tests for	Detection rate	False positive rate	Results available
Full Integrated test	Down Syndrome, Trisomy 18, open neural tube defects	94%	5%	16-20 weeks
Non-invasive prenatal test	Down Syndrome, Trisomy 13, Trisomy 18	99%	0.5% (high risk) Up to 50% (low risk)	10 or more weeks
AFP test	Open neural tube defects	80%	5%	16-22 weeks

Diagnostic Tests
Diagnostic testing options include Chorionic Villus Sampling and Amniocentesis. Please let your physician know if you are interested in either of these testing options.

Facts to consider

Diagnostic tests are more invasive and therefore less safe, but are more accurate
Screening tests are safer but don’t give you a “yes or no” answer
The genetic conditions being tested for cannot be “fixed”, even if we know about them in advance. Having information regarding your baby’s genetics allows your provider to optimize your care and your baby’s care during pregnancy.
Prenatal testing is done to gather information, not to find abnormal babies for pregnancy termination. Many parents who would not terminate an abnormal pregnancy have prenatal testing done in order to be prepared for their newborn’s special needs.
Many mental and physical handicaps are not due to chromosome abnormalities or anatomic abnormalities, and are therefore not detectable by blood tests, ultrasounds, or amnio/CVS.

Find your age-based risk

Age at delivery	Down Syndrome risk (Trisomy 21)	Total risk for Trisomy 21, Trisomy 18, and Trisomy 13
33	1/625	1/345
34	1/500	1/277
35	1/385	1/204
36	1/303	1/167
37	1/227	1/130
38	1/175	1/103
39	1/137	1/81
40	1/106	1/63
41	1/81	1/50
42	1/64	1/39
43	1/50	1/30
44	1/38	1/24
45	1/30	1/19

Adapted from Schreinmachers, DM, Cross, PK, Hook, EB. Rates of trisomies 21,18,13 and other chromosome abnormalities in about 20,000 prenatal studies compared with estimated rates in live births. Hum Genet 1982; 61:318. In UpToDate.

Cystic Fibrosis Carrier Screening

What is Cystic Fibrosis?
Cystic fibrosis is a genetic disorder in which an abnormal gene is passed from parents to their children. It is an illness that does not have a cure, though treatment options are available. CF affects all of the organs in the body, but it most commonly causes problems with the gastrointestinal and respiratory systems. It does not affect a person’s physical appearance or mental abilities. The chances of being a carrier is 1 in 20.

What is Cystic Fibrosis carrier screening?
Cystic Fibrosis is a recessive trait, which means that people can carry the gene that causes cystic fibrosis without actually having the illness. These people are called “carriers”. If two carriers have a baby, there is 25% chance that their child will have cystic fibrosis. Carrier screening is a blood test that can be performed before or during pregnancy to determine whether or not a mother carries this gene.

Is testing covered by my insurance?
Although this simple test is highly recommended, insurance coverage varies greatly. For this reason, it is recommended that patients check with their insurance company to see if this test is covered. To check coverage, call the customer service number on the back of your card and give the representative the following information:

Diagnosis Code:

If you are not pregnant: Z14.1 (Cystic Fibrosis Screening)
If you are pregnant: Z14.1 (Cystic Fibrosis Screening)

Test Code: 81220

What if my test is negative?
A negative test indicates that your risk of being a CF carrier is extremely small. No additional testing is recommended for you or the baby’s father.

What if my test is positive?
A positive result indicates that you are a carrier of the abnormal gene that causes Cystic Fibrosis. If your test is positive, your doctor will recommend that the baby’s father undergo the same testing.

What if I’ve been tested in the past?
If you have had a cystic fibrosis carrier screen in the past, please tell us! Your result will not change, so repeating the test is not necessary. We will simply add your result into your medical record.

Insurance Codes for Prenatal Labs

Test	Code(s)
Cystic fibrosis	81220
Combined Test	84163; 84702
Serum Integrated Test	84163; 82105; 82677; 84702; 86336
Full Integrated Test	84163; 82105; 82677; 84702; 86336; 76813
Quad Test	82105; 82677; 84702; 86336
Alpha-Fetoprotein	82105
Non-Invasive Prenatal test**	81420
Nuchal Translucency Ultrasound	76813
Fragile X Syndrome	81243
Sickle Cell	85660 and 83021
Spinal Muscular Atrophy (SMA)	81401 Sent to Mayo Lab
Tay Sachs	81255
Ashkenazi Jewish mutation panel	81200, 81209, 81242, 81251, 81412 ** Please note that this panel DOES NOT include testing for Cystic Fibrosis, but ordering concurrently is recommended.

Diagnosis code for Labs (use the code that applies to you)
Z34.01 Normal first pregnancy in first trimester
Z34.81 Normal pregnancy (other than the very first) in first trimester
Z36.82 Encounter for Nuchal Translucency ultrasound

*Pricing for the above tests is determined by the performing lab and is subject to change. Please call the labs listed below for pricing if your chosen testing is not covered by insurance.

Sparrow Hospital: 517-364-6000

**Pricing for Non-Invasive Prenatal Tests is determined by the performing lab and may differ from insurance quotes. Ariosa Diagnostics, the lab that performs and bills for the Harmony Prenatal test located in California may be “out-of-network” for your insurance carrier. We therefore encourage you to call Harmony Client Services (1-855-927-4672 option 1) PRIOR to having your blood drawn for the test. A Billing Specialist will be able to review your unique insurance plan to provide you with more specific information regarding your cost for the Harmony Test.

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