Clinical Practice Resources

Nova Scotia care providers have identified a need for additional information and guidance with assisting pregnant persons who choose self-pay non-invasive prenatal testing (NIPT). The following document provides information as a measure to assist with meeting this need.

Please note: the information related to sample collection locations is applicable only to the Dynacare vendor and is accurate as of the date on this document / date posted to the RCP website. Additional locations are evolving and are being added over time. Care providers are encouraged to contact the specific vendor for additional details regarding sample collection locations.

This resource has been developed by care providers at IWK Health with contribution from the Reproductive Care Program. The goal is to offer prenatal care providers across Nova Scotia with an information resource that will guide pregnant persons regarding fetal movement.
Feel free to print the resource for easy reference and / or posting within your clinical spaces.

These guidelines have been developed through consultation with Diagnostic Imaging and the Fetal Assessment & Treatment Centre at the IWK Health Centre. The goal is to provide optimal prenatal care while balancing the impact of hospital visits on the health of the public and our staff.

This practice resource provides prenatal care providers with screening and treatment guidance for anemia in pregnancy, based on evidence as of the date of the most recent version. The algorithm distinguishes between the types of anemia that may be encountered, presents the health professional with the most appropriate treatment options, and provides recommendations for follow-up assessments.

This questionnaire has been developed in the Perinatal Centre at the IWK to support the antenatal care providers of pregnant patients who test positive for COVID-19 (and who are isolating at home). As numbers increase it has become less feasible for health professionals to call patients daily to check in. Some language in the document is specific to the IWK facility, but feel free to adjust it to suit your facility’s needs if you think this would be helpful. Also, feel free to share with your colleagues who provide antenatal care in their own offices.

Points for using this document include:

1. Care providers, once made aware that the patient is COVID positive, should reach out once to the patient using the attached document for guidance. In addition the patient should be advised that should they have any pregnancy-related concerns they can contact their care provider, or contact the labour/birth unit and speak to the charge nurse.  If they have questions related to COVID testing, isolation etc, they should contact Public Health, or in some cases, depending on where they work, their occupational health office. If they have concerning COVID-related symptoms (worsening cough or shortness of breath for example) they should proceed to the ED. Emergent pregnancy-related concerns should be addressed in the labour assessment area if at all possible in your facility.
2. Pregnant patients who have had a positive rapid swab should be advised to get a PCR. Pregnancy remains a reason for a PCR. Patients should indicate that they are pregnant when they book the swab. With luck that will alert the care provider that an O₂ sat monitor is needed.
3. Some people have asked about CCVCT. It is the Community COVID Virtual Care Team. They are  still trying to ensure that patients have O₂ sat monitors but can only do so if the patient has a confirmed PCR and has indicated that they are pregnant. If the patient has not received an O₂ sat monitor you (or the patient) can email CCVCT@nshealth.ca.
4. Please ensure you have documented the patient’s COVID positive status on their prenatal record.
5. Generally COVID positive individuals are cleared 10 days from symptom onset or, if asymptomatic, 10 days from their positive swab. Public health guidance will help to advise regarding this.
6. Dr Heather Scott is making every effort to collect information regarding these patients and enroll them in the CanCOVID study. In order to do so, she needs to be aware that there has been a positive test. The patient needs to agree to have a study person from the IWK call them and explain the study (not a formal consent, just an agreement to be called – the IWK will obtain study consent). Please email Dr Scott (heather.scott@iwk.nshealth.ca) when you have a patient with a positive test, to let her know whether the patient has agreed to a phone call to explain the study. 

There are lots of questions about vaccines and boosters and we are really trying to encourage them in pregnancy and in those who are breastfeeding. For information related to the COVID-19 vaccine in pregnancy, click here

This practice resource, developed in September 2021 and revised in February 2022, provides information to care providers related to a new approach to GDM screening in Nova Scotia. The practice resource has been informed by evidence and has been adapted specifically to Nova Scotia’s context and population of pregnant persons. It includes the Diabetes Care Program of Nova Scotia GDM screening practice algorithm and information related to the interpretation of testing results.

In January 2022, Central Zone Pathology and Laboratory Medicine issued a memo outlining the process for ordering HbA1C based on the new provincial approach to GDM screening.

In June 2022, the Diabetes Team at the IWK issued a memo outlining operational changes in their approach to diabetes and ultrasound surveillance for diabetic patients.

Additionally, you may watch New Approach to GDM Screening in Nova Scotia, a recorded presentation given by Dr. Jillian Coolen on October 25, 2021 as part of RCP's Webinar Series.

Pregnancy and Diabetes: Approaches to Practice (2021): This resource, published by the Diabetes Care Program of Nova Scotia (DCPNS), provides health care providers with additional information in support of recognized Clinical Practice Guidelines for the management of pregnancy complicated by diabetes.

The Nova Scotia Vaccine Expert Panel has updated resources for care providers to use with pregnant and breastfeeding individuals to guide discussion about COVID-19 vaccination. This information is specific to adult immunization.

In addition to these documents, the IWK has produced a video to help individuals make an informed choice about whether to get the COVID vaccine while they are pregnant, trying to get pregnant or breastfeeding. The video is hosted on the IWK public website: https://www.iwk.nshealth.ca/COVID-19/vaccine-info-for-pregnant-or-breastfeeding

For more resources related to the care of pregnant patients and their newborns affected by COVID-19, please refer to our COVID-19 Resources page.

Accurate assessment of gestational age is crucial:

1. to determine viability of extreme preterm birth
2. to properly interpret maternal serum screening for aneuploidy
3. to prevent post term induction of labour and
4. to optimize obstetric care including avoiding inappropriate perinatal interventions.

Consistent approaches to gestational age assessment must also be taken to optimize accuracy.

This provincial guideline has been revised to reflect the recommendations of national professional organizations and local experts, within the context of Nova Scotia perinatal care provision. As such, these guidelines may differ from those found in other jurisdictions. The RCP acknowledges the Divisions of Maternal Fetal Medicine (MFM) and Neonatal Perinatal Medicine (NPM) at the IWK Health Centre, for their collaboration in producing this guideline.

Syphilis and Screening in NS for Pregnant Persons and Newborns

The rate of syphilis in Canada has been steadily rising in recent years, becoming a significant public health concern. A surge in syphilis infection among women of childbearing age has led to more cases of congenital syphilis (transmission from the pregnant person to the fetus during pregnancy), which can result in severe health outcomes or death in newborns. An infographic created by the Public Health Agency of Canada provides a visual aid depicting the increase in syphilis rates in Canada. Cases of syphilis in pregnancy and confirmed cases of syphilitic stillbirth are reportable to Public Health. The rise in cases has led to national research exploring strategies to address infectious and congenital syphilis in Canada. 

Screening

Screening recommendations for syphilis during the antenatal and postpartum periods, and for newborns are provided below.  These recommendations have been in place since 2020, were adapted from national guidelines, and remain in place until further notice. See the letter to care providers from January 2020 for additional practice guidance regarding consultation, testing and treatment.
Perform syphilis serology:

• Early in pregnancy for all pregnant persons.
• Repeat for all pregnant persons at 24 -28 weeks gestation.
  • For patients considered at high risk for syphilis, repeat syphilis serology at the time of birth.
• For patients considered at high risk for syphilis, repeat syphilis serology at the time of birth.
• In pregnant persons who experience a stillbirth from 20 weeks gestation onward.
• In pregnant persons who have NOT had the recommended syphilis serology during pregnancy, complete the screening prior to discharge following birth.
• In infants presenting with symptoms or signs compatible with early congenital syphilis even if the parent was seronegative at birth, due to the possibility of a very recent parental infection. 

Provincial Syphilis Outbreak: Recommendations for pregnant persons and newborns

As of January 20, 2020, the Office of the Chief Medical Officer of Health for Nova Scotia has declared a provincial syphilis outbreak. Across Canada syphilis outbreaks have been declared in most provinces/territories, due to increasing rates of infection. Changes to recommendations for pregnant women and newborns are outlined in the documents below:

The Canadian Paediatric Society (CPS) has recommended moving from universal newborn ocular prophylaxis, to universal prenatal screening for Neisseriae gonorrhoeae (GC) and Chlamydia trachomatis (CT) and treatment of those with positive results in order to eradicate infection and prevent intrapartum transmission to the newborn.

As universal ocular prophylaxis is eliminated from routine newborn care, functions of the health system must be optimized and synchronized to prevent ON. RCP has partnered with clinical experts and stakeholders from across NS to produce these resources, which are designed to offer guidance for the prevention of ON:

Key messages for health care providers

• Black-legged or deer ticks (BLT) are found throughout Nova Scotia. Preventing a BLT bite is the most effective way to prevent Lyme disease. Risk reduction strategies include using DEET-containing insect repellant (safe to use in pregnancy) and careful ‘tick checks’ after being in grassy or wooded areas, including a park or yard. Immediate and correct removal of an attached BLT is key to prevention. For advice about tick removal see: https://novascotia.ca/dhw/CDPC/lyme.asp.

• Prophylaxis may be considered. A single 200 mg dose of doxycycline, which is not contraindicated for pregnant women, may be offered if all of the following criteria are met.
  • BLT attached for > 24 hours, AND
  • antibiotic prophylaxis is given < 72 hours from tick removal, AND
  • the bite occurred in an area considered at higher or moderate risk for Lyme disease, which is most of NS. For risk level by NS County see map at this link: https://novascotia.ca/dhw/CDPC/lyme.asp.

• The risk of Lyme disease after a bite from an infected BLT is low (1.2%-3.2%). However, if a bite occurs advise observation for signs and symptoms for 30 days, even if there has been prophylaxis.

• Think about Lyme disease in your differential for a patient presenting with new onset febrile illness, especially when associated with a localized skin lesion. Early infection is a clinical diagnosis.  The sensitivity of two-tiered serologic testing, the recommended testing standard in Canada and the US, is < 50% in early, localized Lyme disease. The test performs well in early disseminated and in late Lyme disease. For information about testing see: https://novascotia.ca/dhw/cdpc/documents/statement_for_managing_LD.pdf.

• Treatment for pregnant women with Lyme disease is similar to treatment for the general adult population, with the exception that treatment doses of doxycycline are contraindicated in pregnancy. With 10-28 days of oral antibiotic treatment, 95% of cases of Lyme disease are resolved. For treatment recommendations see: https://novascotia.ca/dhw/cdpc/documents/statement_for_managing_LD.pdf

• There is not enough evidence to confirm that Lyme disease during pregnancy has adverse effects for the fetus. In addition, no adverse effects for the fetus have been observed when the pregnant woman receives appropriate antibiotic treatment for her Lyme disease.

• There have been no reports of Lyme disease being spread from mother to child through breast milk. Treatment of Lyme disease while breastfeeding should also not have consequences for the child. https://www.canada.ca/en/public-health/services/diseases/lyme-disease/pregnancy.html

For more information about Lyme disease, refer to the following resources:

From the Government of Canada and the Public Health Agency of Canada

• https://www.canada.ca/en/public-health/services/diseases/lyme-disease.html
• https://www.canada.ca/en/public-health/services/diseases/lyme-disease/health-professionals-lyme-disease.html
• https://www.canada.ca/en/public-health/services/diseases/lyme-disease/pregnancy.html

From the Nova Scotia Department of Health & Wellness

• https://novascotia.ca/dhw/CDPC/lyme.asp  
• https://novascotia.ca/dhw/cdpc/documents/statement_for_managing_LD.pdf

TO: NS Perinatal Care Providers
FROM: Reproductive Care Program
DATE: December 1, 2017
RE: Zika Virus in Pregnancy

Recommendations for screening pregnant women with potential exposure to Zika virus are evolving. The current screening recommendations are summarized below. Included with this memo are copies of the Nova Scotia ZIKA TESTING ALGORITHM – INTERIM GUIDANCE and the Nova Scotia ZIKA CLINICAL INFORMATION DATA SHEET – INTERIM GUIDANCE.

• All pregnant women with a potential exposure to Zika virus require assessment, regardless of whether they develop symptoms. Potential exposure is defined as personal travel to a Zika area any time after the date of the woman’s LMP or unprotected sexual contact with a male who has traveled to a Zika area in the last 6 months. For the most recent Zika Virus Travel update refer to the PHAC website at http://travel.gc.ca/travelling/health-safety/travel-health-notices
• Symptomatic pregnant women should be referred to the Fetal Assessment & Treatment Centre (FATC) at the IWK. These women will need blood and urine specimens collected and sent to the Department of Pathology and Laboratory Medicine, Central Zone as described in the ZIKA TESTING ALGORITHM. The ZIKA CLINICAL INFORMATION DATA SHEET must be completed and sent with the specimens.
• Asymptomatic pregnant women who have traveled to a Zika area since their last LMP, or have had unprotected sexual contact with a male who has traveled to a Zika area in the last 6 months, should be referred to the FATC for triage. All should be offered Zika virus serology as described in the ZIKA TESTING ALGORITHM and the ZIKA CLINICAL INFORMATION DATA SHEET must be completed and sent with the specimens.  Consultants in the FATC will determine the best timing and location for ultrasound surveillance based on the woman’s individual circumstances, such as timing of exposure and gestational age.
• The FATC referral form should include the woman’s LMP, the circumstances of her exposure in the context of gestational age (include travel history or history of unprotected sexual contact with a male who may have been exposed to Zika virus), the presence or absence of symptoms consistent with Zika virus in the woman or her partner, the timing of the appearance of symptoms (if relevant), whether or not a blood sample has been sent for Zika serology and, if so, the date the sample was collected.
• The timing of Zika serology is important.  Zika serology for an asymptomatic pregnant woman should be done NO SOONER than three weeks following the last exposure. At this time Zika serology for male partners of pregnant women is not being offered in Canada. Because all testing is done at one lab in Winnipeg the priority is pregnant women. In addition, the interpretation of a negative test in this context is difficult.
• The FATC referral form can be found at: http://www.iwk.nshealth.ca/sites/default/files/IWK_MAFE.pdf or on the IWK website under the tab, ‘For Health Professionals’ and the option ‘Referral Forms for External Physicians’.  A new form must be printed for each referral (due to the barcode) and the form must be faxed to FATC at 902-470-7987.
• Remind each pregnant woman that her male partner should use condoms for the duration of the pregnancy.
• Remind each woman who could become pregnant, that her male partner should use condoms for 6 months from the time of travel to a Zika area. If a woman becomes pregnant within two months of personal travel to a Zika area, or within 6 months of her male partner traveling to a Zika area, the need for testing must be assessed on an individual basis through the FATC.
• More detailed information, including links to all current national and international recommendations for pregnant women with regard to Zika virus exposure, is available from the Society of Obstetricians and Gynecologists of Canada at:  https://sogc.org/news-items/index.html?id=135

Nova Scotia recommendations related to pregnancy and Zika virus exposure will be updated on the RCP website as new information becomes available.  Please check back regularly at http://rcp.nshealth.ca

A detailed guide and reference for prenatal care providers using the Nova Scotia Prenatal Record to document assessment, investigation and treatment during pregnancy. Includes instructions on assembly of the prenatal record, a glossary of terms related to pregnancy and prenatal care, details on completing each section of the record, guidelines for antenatal screening and related resources.