Antenatal Care

Presented by: Team 1

Mohammed Alshehri – AU ID: 130127

Sultan Alsobayeg – AU ID: 130351

Objectives Preconception care: indications, advice

What is antenatal care

Aims of antenatal care

The booking visit

Dating the pregnancy

Booking history, examination and investigations

Screening for maternal diseases, fetal abnormalities

Teratogenicity, teratogenic medications

Genetic counselling

Ultrasound: indications and timing

Follow-up and frequency of visits

Common/ minor pregnancy problems: hyperemesis, constipation, heartburn

General advise: life style, nutrition

Preconception Care: Indications & Advice

• Up to 30% of pregnant women begin traditional prenatal care in the second trimester, which is after the period of organogenesis

• Improving the health of women before pregnancy is essential

Aims of preconception care:

• Avoid behaviors and exposures known to adversely affect pregnancy outcomes

• Provide an opportunity to inform women about pregnancy issues

• Identify some of the risks of pregnancy for the mother and fetus and educate them about these risks

• Institute appropriate interventions when possible, before conception

Preconception Care: Indications & Advice

• A set of interventions that aim to identify and modify biomedical, behavioral, and social risks to a woman’s health or pregnancy outcome through prevention and management

• Preconception intervention is more important than prenatal intervention for prevention of congenital anomalies

• Prenatal care should begin before pregnancy & more than one visit

• Data shows that 4 out of 10 women report that their pregnancies are unplanned

• 1/2 of all pregnancies in USA are unplanned

• As a result preconception counseling is recommended for every woman of reproductive age

• Examples: obesity control, smoking cessation, exposure to toxins, HIV/AIDS screening and treatment, and genetic disorders screening

What is Antenatal Care?

• The care provided for pregnant women & her unborn baby throughout a pregnancy

• Before 10 weeks

• Influences the outcome of the pregnancy

• Patients are advised to follow up with regular visits

• Providers: Obstetricians and Gynecologists, Family physicians and Midwives

• Medical check up every four weeks up to 28 weeks gestation

• Every 2 weeks until 36 weeks

• Every week until delivery

• An average of 7 to 11 visits

• More visits may be required if complications arise

Aims of Antenatal Care

• To educate mothers about pregnancy, childbirth and child care

• To screen for and detect factors which might adversely affect the health of mother and/or fetus

• To deal with minor pregnancy problems

• To control pre-existing diseases to avoid exacerbations with adverse outcome on mother and/or fetus

• Final aim: healthy mother and child

The Booking Visit • The Booking (first) visit is a very important component of antenatal care

• In the first visit, basic medical information is collected to follow the patient throughout pregnancy

• Subsequent visits are often scheduled about every four weeks during the first trimester & will probably be shorter than the first

• Confirmation of pregnancy: WHAT IS REQUIRED?

1- Symptoms of pregnancy (amenorrhea, breast tenderness, nausea, increased frequency of urination etc.)

2- +ve βhCG in urine and serum 7 – 10 days after conception

3- US to confirm + date pregnancy

• Dating the pregnancy: Precise dating is very important for both preterm gestations and post term deliveries

• History & Physical Examination

• Investigations

Dating the Pregnancy • Menstrual EDD:

Using Naegele’s rule: LMP + 7 days + 9 months (or subtract 3 months)

This rule assumes a regular 28 day menstrual cycle with ovulation on the 14th day and an accurate recollection of the LMP

• Ultrasound dating

• Accurate dating of pregnancy in women with: poor recollection, irregular cycles, and for early detection

• Before 15-16 weeks minimal variation in fetal size; plotted on standard charts and gestation calculated accurately

• If EDD predicted by dating scan differs from menstrual EDD by >7 days Go with scan EDD

• Beyond 20 weeks Genetic and environmental factors cause significant variability ↓ accuracy

• Dating scan is also helpful and more accurate because not all women have a 28 day cycle, a regular cycle or accurate recollection. This also decreases the chances of labour induction for supposedly prolonged pregnancies or anxiety regarding supposedly preterm deliveries. Early detection of multiple pregnancies, screening for various diseases/abnormalities is another benefit of getting a dating scan

• Ultrasound – “crown rump length”

• Most accurate method

• Crown-rump length (CRL) measurement of length of fetus from top of head (crown) to bottom of buttocks (rump)

HistoryAIM: identify risks

Age and racial origin:

• Extremes of age ↑ risk of pregnancy related complications

• Certain racial groups carry ↑ risk of medical conditions

Past medical history:

• Chronic illnesses

• Treatment (rule out teratogens)

• Hospitalisations, surgeries and blood transfusions

Past obstetric history:

• GTPAL and details of each pregnancy

• Previous complications

• Method of delivery

• Outcome of each pregnancy (gender, well/not well etc.)

Past gynaecological history

• History of infertility or recurrent pregnancy loss

• Menstrual History

• Surgeries, infections etc

Family history:

• FHx of Type 2 DM +ve ↑ risk of developing gestational diabetes

• Thromboembolic diseases linked to ↑ risk of DVT pulmonary embolism

• Chromosomal anomalies, single gene disorders etc

Social History:

• Smoking and alcohol exposure

• Non prescription drugs

• Social deprivation

• Neglect and abuse

Physical Examination• Introduce yourself, obtain consent, Wash your hands & obtain a chaperone for

assistance

• Height and weight/BMI

• <19 BMI associated with low birth weight

• >29 BMI associated with complications such as pregnancy induced hypertension, diabetes and macrosomia

• Vital signs

• General physical exam

• Specific examination if indicated

• Abdominal exam

• Pelvic exam

• Discharge

• Cysts

• Lesions (e.g. herpes)

• Adnexal masses

Fetal heart: can be heard by Doptone around 12 weeks Place Doptone just above

pubic symphysis and aim transducer towards feet/spine

Investigations • CBC; Hemoglobin, hematocrit and platelet count

• MCV <80 without the presence of iron deficiency anemia can indicate an underlying sickle cell disease or thalassemia

• ABO and Rh type: Direct Coomb’s test

• Hepatitis B surface antigen (HBsAg)

• STDs, gonorrhea and chlamydia

• Syphilis screening (VDRL, RPR)

• Rubella Titer

• HIV

• Urinalysis and culture: asymptomatic bacteriuria

• Targeted tests: Hb electrophoresis, sickle cell, infection

• Screen for diabetes – highly prevalent in our society

• Consider Thyroid function tests (TFT) – highly prevalent in our society

Screening for Maternal Diseases and Fetal Abnormalities

• First and second trimester testing

• Can be invasive or non invasive tests

• Commonly used techniques:• Maternal serum screen (β-hCG, AFP, PAPP-A)

• Ultrasound

• Amniocentesis

• Chorionic Villus Sampling (CVS)

• Cordocentesis

Screening for Maternal Diseases and Fetal Abnormalities

Prenatal diagnostic testing performed when there is:• FHx genetic disease with known mutation and recurrence risk

• Past ob Hx; Rh isoimmunization

• Abnormal screening test (serum, or ultrasound)

• Abnormality in ultrasound

Additional diagnostic testing for mothers who have:• Pre-existing maternal diseases (i.e., diabetes, kidney disease, heart

disease)

• Toxemia

• Abnormal amniotic fluid amounts

• Abnormal fetal growth

• Multiple pregnancy

• Post-term pregnancy

First trimester screening:• Maternal age

• Fetal nuchal translucency (NT) thickness: • ↑ NT associated with chromosomal and congenital anomalies.

• Maternal serum free β-hCG • (↑ β-hCG ↑ risk of Down syndrome)

• Pregnancy associated plasma protein A (PAPP-A) • (↓ PAPP-A ↑ risk of Down syndrome)

Nasal bone assessment on ultrasound can ↑Down syndrome detection rate

Second trimester screening: “serum triple screening test”:

• Alpha-fetoprotein (AFP) detection of neural tube defects

• hCG

• Unconjugated estriol (UE3)

• ↓ MSAFP + ↑ hCG + ↓ UE3 Screen for Down syndrome

• ↓ MSAFP + ↓ hCG + ↓ UE3 Screen for trisomy 18

Teratogenicity • Tetracycline

• Pregnancy category - D

• Trimesters of risk - Second and third (20th gestational week or later)

• Associated defects and complications - Dental staining

Teratogenicity • Warfarin

• Pregnancy category - X

• Trimesters of risk - First, second, and third

• Associated defects and complications - Malformed intestines, hearing defects, absent ears

Teratogenicity • Thalidomide

• Pregnancy category - X

• Trimesters of risk - First, second, and third

• Associated defects and complications - Deformities of the axial and appendicular skeleton

Genetic Counseling• Down's syndrome (between 11-14 weeks)

• Thalassemia

• Sickle cell anemia

• Patau's syndromes

Genetic Counseling

• Chorionic villus sampling (12 weeks):

A sample of placental tissue is obtained for analysis under ultrasonographic guidance

Genetic Counseling

•Amniocentesis (15-22

weeks ):

The procedure consists of the aspiration of amniotic from an amniotic fluid pocket with a ultrasonographic guidance

Genetic Counseling• Cordocentesis PUBS (20

weeks) :

The greatest advantage of this technique is that it provides a direct fetal sample, but still carry a high risk of fetal loss and placental abruption

Ultrasound• The basic obstetric ultrasound is categorized by the

gestational age at which it is performed

• First trimester:

1-Mainly to confirm the pregnancy

2- Nuchal translucency

3-Anencephalia

Ultrasound• Second trimester (Anatomy ultrasound):

1-Aneuploid

2-Placental evaluation

3-Fetal growth

• Any trimester:

1-Fetal heart tones

2-Evaluating preterm labor

3-Determining fetal presentation

Follow Ups• The Traditional antenatal care includes a series of between 7 and 11 visits

• A comprehensive physical examination should be performed at the first or second visit

Follow Ups• Typical frequency of visits in an uncomplicated pregnancy:

• Every 4 weeks for the first 28 weeks

• Every 2 to 3 weeks between 28 and 36 weeks

• Weekly after 36 weeks

• Psychosocial screening to evaluate any existing anxiety, depression and other aspects

• Undergo influenza vaccination, tetanus toxoid and reduced diphtheria toxoid

Follow Ups•Ask about:

pain, fetal movement, contraction frequency, vaginal bleeding, loss of fluid or discharge, preeclampsia symptoms in addition to any other patient-provided complaints or concerns

Common Symptoms of Pregnancy

•Hyperemesis Gravidarum:

• Early in the first trimester

• The pathogenesis of hyperemesis gravidarum is poorly understood. Hormonal and psychologic factors may play a role

• Treatment of hyperemesis gravidarum focuses on replenishing fluids, electrolytes, vitamins, and minerals

Common Symptoms of Pregnancy

• Gastroesophageal Reflux Disease (Heart Burn):

• Both mechanical and intrinsic factors are involved in GERD

• Fifty-two percent of pregnant women first experience GERD in their first trimester, 24-40% experience it in their second trimester, and 9% in their third trimester

• Lifestyle modifications and pharmacologic management

Common Symptoms of Pregnancy

• Constipation:

The etiology is multifactorial, with decreased small bowel motility, decreased motilin level, decreased colonic motility, increased absorption of water, and iron supplementations possible contributory factors

Stool softeners such as sodium docusate are probably safe. Stimulant laxatives are probably safe for intermittent use, but these agents should not be used regularly. Castor oil and mineral oil should not used in pregnancy

General Advice

• Life Style

***Do your daily activities***

•Nutrition

***Balanced diet + fluids + vitamins***

References• Uptodate.com

• Medscape.com

• Webmd.com

• Presentations of Alfaisal’s faculty

• Presentations of Dr Kurdi

• Student presentation from last year

The End

Thank you