U.S. Medicine E-Prescribing April Andrews, former Army Medic, delivered her baby in 2014 with care covered through VA maternity care benefits at the Salt Lake City VAMC. Point-of-care testing is increasingly used to make sure pregnant veterans get the highest quality care. Photo from VAntage Point blog.

NEW YORK — From 2000 to 2014, the number of women veterans receiving care through the VA doubled. Today, approximately 750,000 women are enrolled in the VHA healthcare system and about half a million use it each year.

The dramatic rise in women using VA services has driven significant changes in the services and equipment available, including the addition of mammography machines, ultrasound and biopsy equipment, DEXA scans. It has also sharply increased the use of point-of-care testing.

“We have an increasing number of women coming into the VA health care system and the majority of them are of childbearing age. VA understands that our women Veterans have special health care needs across their lifespan,” said Laurie Zephyrin, MD, MPH, MBA, VA’s acting assistant deputy undersecretary for Health for Community Care.

Zephyrin is keenly aware of the needs of women veterans. She served as the VA’s first national director of Reproductive Health, where she was responsible for developing new strategies and programs to optimize reproductive healthcare and training providers to effectively treat urgent problems in women such as abnormal bleeding, pelvic pain and pregnancy-related issues.

The increased focus on women’s health drove structural, process and technological changes at medical centers and community-based outpatient clinics (CBOCs). “We hired physicians to do women’s exams, added exam rooms and women’s bathrooms to provide privacy,” said Sharon Fry, BSMT, ancillary testing supervisor at Hunter Holmes McGuire VAMC in Richmond, VA. “We also started doing more Pap smears, vaginitis tests and hCG [human chorionic gonadotropin] tests.”

For women, in particular, “point-of=care testing is very important in some cases,” Zephyrin told U.S. Medicine. “You need the quick turnaround time and access to more sensitive tests.”
HCG tests, for instance, are used to determine whether a patient is pregnant. The test detects the presence of the hCG hormone, which is produced by the placenta during pregnancy, circulating in a patient’s blood or present in her urine. The quantitative beta-hCG test measures the level of the hormone in blood.

“In the emergency department, if a woman veteran needs to have imaging, we have to make sure she’s not pregnant before she receives the contrast medium for an MRI,” Fry told U.S. Medicine. Research recently published in JAMA found that contrast agents that use gadolinium in the first trimester of pregnancy tripled the risk of stillbirth or newborn death and increased the risk of certain chronic conditions in infants.1

Other Risks

Pregnant women veterans face other risks, too. “If you are in a clinic without a lab, you’ll have a problem if you need to do a radiology study or want to prescribe teratogenic drugs” for a woman of childbearing age, said Michael Icardi, MD, the VA’s national director of Pathology and Laboratory Medicine Services.

Particularly in an emergency department setting, more sensitive hCG tests can make a difference in care received and appropriate diagnosis. A large study at Mount Sinai Beth Israel in New York published in the Annals of Emergency Medicine determined that the use of a common urine pregnancy test produced “unacceptably high” false negative results. The study analyzed 17,227 urine pregnancy tests taken by 12,764 patients, of which 9% had same-day serum hCG testing. They found 10.5% of visits with comparison available had false negative urine results. The false negatives included at least 11 new ectopic pregnancies, of which two were missed, and one molar pregnancy. Ectopic pregnancies are the leading cause of maternal deaths in the first trimester of pregnancy.2

Another study found that nine of the 11 most commonly used urine pregnancy tests in U.S. hospitals produce false negative results after five to seven weeks of pregnancy, as rising concentrations of hCG beta core fragments interfere with their accuracy. “In centers where quantitative blood hCG testing is available, this should be the preferred pregnancy test. Blood testing is not subject to this effect because hCG beta core fragment is not present in serum,” said the study’s lead author Ann Gronowski, MD, of the Washington University School of Medicine in St. Louis. In addition, early gestational age and dilute urine may produce false negatives in urine tests.3

“Sensitivity makes a big difference in pregnancy tests,” said Icardi. “If it’s detecting at 100 IU/L, like traditional pregnancy tests, then you get a positive result at 1-1.5 months after implantation. At 20-25 IU/L, which is about the level most good home pregnancy tests can detect today, you can get a positive result two to three weeks earlier,” at about three weeks to a month after implantation.

Hospital urine tests detect hCG at about the same concentration, though at low levels of hCG even trained laboratory technicians may have difficulty properly interpreting the results, according to an article in Clinical Chemistry.4

Blood tests can detect pregnancy at less than 5 iu/ml, said Zephyrin, which corresponds to about a week after implantation. Some blood tests, including popular point of care cartridge systems, can identify hCG at significantly lower levels.

The i-STAT system is among the point of care cartridge systems frequently used at the VA. Using two or three drops of whole blood, it can detect a pregnancy within seven days of implantation—and give those results to the clinician in about two minutes. “The lower threshold allows us to detect pregnancy even earlier,” Zephyrin said. “Being able to assess pregnancy at the point of care has significant value.”

The rapid response allows clinicians to “diagnose and treat a veteran as appropriate, reduce on turnaround time and see patients more expeditiously,” Fry said. “By doing a screen at the time the patient is seen by the provider, it allows actions to be taken in a swift manner so the results can be reviewed with the veteran during the visit and she doesn’t have to come back again. It makes follow up less of a burden for everyone.”

Veterans value that, regardless of where they seek care. “The advantage of a point-of-care system is that clinicians can follow up immediately and monitor the patient more closely, particularly at facilities that are located at some distance from the main lab. In some instance, facilities may be using i-STAT even in the main lab to reduce the load on the nurses and doctors,” while still getting rapid results, Zephyrin said.

Knowing about a veteran’s pregnancy affects the other care she receives as well, she noted. “For pregnant patients, we know reference ranges change with volume expansion and that affects the standards used for hematocrit and other tests. It also alerts us to check for gestational diabetes.”

1Ray JG, Vermeulen MJ, Bharatha A, Montanera WJ, Park AL. Association Between MRI Exposure During Pregnancy and Fetal and Childhood Outcomes. JAMA. 2016 Sep 6;316(9):952-61. doi: 10.1001/jama.2016.12126.Woo KM, Director T, Sweeney C, Cristales D, Deguia J, Baumlin K.

2417 False Negative Point-of-Care Urine Pregnancy Results in the Emergency Department: Quatifying a Needle in the Haystack in the Clinical Setting. Ann Emerg Med. 2015 Oct;66(4):S150.

3Nerenz RD, Song H, Gronowski AM. Nerenz RD, Song H, Gronowski AM. Screening method to evaluate point-of-care human chorionic gonadotropin (hCG) devices for susceptibility to the hook effect by hCG β core fragment: evaluation of 11 devices. Clin Chem. 2014 Apr;60(4):667-74. doi: 10.1373/clinchem.2013.217661.

4Nerenz RD, Gronowski AM. Qualitative Point-of-Care Human Chorionic Gonadotropin Testing: Can We Defuse This Ticking Time Bomb? Clin Chem. 2015 Mar;61(3):483-6. doi: 10.1373/clinchem.2014.233627.