IMPORTANT ASPECTS OF ANTENATAL CARE

PPT MADE BY: DR RAJESH T EAPEN

ATLAS HOSPITAL

MUSCAT, OMAN

NICE/RCOG GUIDELINES – JUNE 2010

Pregnancy is a normal physiological process & any interventions offered should have known benefits & be acceptable to the pregnant women

Current models of ante-natal care originated in the early 20th century.

The pattern of visits recommended at that time (monthly until 30 wks, then fortnightly to 36 wks and then weekly until delivery) is still recognisable today

AIMS OF ANTENATAL CARE

Monitoring the progress of pregnancy with minimum interference

Guidance to the expectant mother Early detection of any deviation from

normal Institution of corrective measures

wherever possible Preparation of the mother for labour &

delivery

PRENATAL CARE

The ideal initial prenatal care visit occurs before conception with a pre-conceptive visit.

A pre-conceptive visit allows modification of behavioral choices, medication, and optimizing medical concerns before conception.

FIRST VISIT – 10 WEEKS

ANC BEGINS AS SOON AS PREGNANCY IS CONFIRMED

CONFIRMATION OF PREGNANCY – UPT

HISTORY TAKING

GENERAL & SYSTEMIC EXAMINATION

INVESTIGATIONS – Hb, RBS, Ur, Blood Group, HIV, VDRL, HbsAg , Sickling Test

USG –Confirming viability & number

Estimation of GA & EDD (10–13wks)

Advice - Do’s And Dont’s DIET WORK & EXERCISE – Continue working till the end & moderate

exercise COMMON SYMPTOMS – Morning sickness, Heartburn, LBA,

Frequency, Vg Discharge, Constipation SEXUAL INTERCOURSE – safe MEDICATIONS – Folic acid & calcium ALCOHOL INTAKE - <1-2 UK units/wk (1 u= half a pint of ordinary

strength lager/beer, or one shot [25 ml] of spirits. One small [125 ml] glass of wine =1.5 UK units)

SMOKING – Quit-LBW, IUGR DRIVING & TRAVEL – Car (seat belts) & Air travel (36wks), travel

abroad & related vaccinations

Seat Belt in pregnant lady – the right way!

SCREENING FOR MATERNAL DISEASES

ANEMIA – Booking – 11 gm%

28wks – 10.5 gm%

No need for routine Iron supplements

SICKLE CELL DISEASE - Sickling test

ALLO-ANTIBODIES - ICT - Routine anti-D prophylaxis at 28 & 36 wks to all non-sensitised pregnant women

Women should be screened for atypical red cell allo antibodies (Kidd, Duffy, Anti-C) in early pregnancy & at 28 weeks, regardless of their rhesus D status

SCREENING FOR FETAL ANOMALIES

DOWN’S SYNDROME- Nuchal Thickness -performed end of first trimester (13w0d-13w6d) – increased >6 mm

COMBINED TEST – NT + HCG + PAPP-A (11w-13w6d)

TRIPLE/QUADRUPLE TEST 15-20wks.

CONTINGENT SCREENING measuring free β-hCG & PAPP-A in all pts at 10 wks -those with low risk are screened negative- remainder NT - 13 wks - low risk are screened negative-others offered marker assays & diagnostic tests.

ANOMALY SCAN - 18w 0d-20w 6d – Optional

TRIPLE MARKER TEST Performed between the 15th & 18th wk.

AFP (fetus), HCG (placenta), and Estriol (both)

High AFP levels - neural tube defects, anencephaly, mistaken dates.

Low AFP & Estriol & High HCG -Trisomy 21 (Down) Trisomy 18 (Edwards) or any other type of chromosome abnormality.

QUADRUPLE TEST

Pts registering in late 2nd trimester-22wks

AFP (fetal liver), Estriol (placenta+fetal liver),HCG (placenta),Inhibin-A (placenta)

High AFP levels - open neural tube defect, mistaken dates or twins.

Low AFP levels - high risk for Down syndrome.

High HCG and Inhibin-A levels - increased risk Down syndrome.

Low Estriol - high risk for Down syndrome

SCREENING FOR INFECTIONS Asymptomatic bacteriuria - persistent bacterial

colonisation of the urinary tract without symptoms.

After the initial screening, patients only need to be screened for UTI infections if they are symptomatic

HIV – MTCT- more than 35% reduced to 5% with ART with ZT(300mg)+NVP(200mg)+3TC(150mg) twice daily-14 wks till BF & 6wks for infant after BF

The combination of ART, LSCS and avoiding breast feeding can further reduce the transmission to 1%.

Latest guidelines – Continue ART + Breast feeding

SCREENING FOR INFECTIONS

HEPATITIS–B - Screening for HBsAg, new sample-confirmatory testing & testing for e-markers to know if baby will need Ig along with vaccine postnatally

RUBELLA - susceptibility screening offered early to identify women at risk of contracting rubella infection and vaccinate in the postnatal period.

SYPHILLIS- TPHA if VDRL is positive

Mother-to-child transmission is associated with neonatal death, congenital syphilis, stillbirth and preterm birth

SCREENING FOR CLINICAL CONDITIONS

GESTATIONAL DIABETES

RBS at booking - less than 130 mg/dl or 7.2 mmol/l

OGCT - 1 hr after 50 gm of glucose - 24wks – h/o GDM–16wks-< 140mg/dl or 7.8 mmol/l

GTT– 75 gm of glucose and 03 days of diet rich in carbohydrates.

Fasting – 104 mg/dl or 5.8 mmol/l

2 hr after glucose – 140 mg/dl or 7.8 mmol/l

A 2 hr 75 g OGTT is used as the gold standard diagnostic test and is assumed to be 100% sensitive and specific

PRE-ECLAMPSIA Pre-eclampsia is a complex disorder with

widespread endothelial damage in all organs, thus presenting signs and symptoms may be more varied than just high BP & proteinuria

Blood pressure measurement and urinalysis for protein–each visit.

Hypertension single diastolic BP of 110 mmHg or any consecutive readings of 90 mmHg on more than one occasion at least 4 hours apart.

Proteinuria 02 clean catch samples-4 hours apart with 2+ proteinuria by dipstick are significant.

300 mg protein in a 24 hour sample

PLACENTA PREVIA

Low-lying placentae - not an uncommon finding on early trimester scans

Most low-lying placentae detected at the routine scan generally resolve by the time the baby is born.

Only a woman whose placenta extends over the internal cervical os should be offered another trans-abdominal scan at 32 weeks.

If the trans-abdominal scan is unclear, a trans- vaginal scan should be performed.

MONITORING FETAL WELL BEING

Clinical Examination – Symphysis-Fundal height – after 24wks (difference of more than 2 cms is significant)

Daily Fetal Movement Count – DFMC–10/12 hrs or 3 in one hr – one hr post meals.

Ultrasound – not accurate in assessing fetal growth in later trimesters

Doppler Studies - in suspected IUGR

CTG/NST– valid only after 32 weeks

Biophysical Profile – Movement, tone, HR (NST), Breathing, AFI – Normal score 8 or more

Modified Biophysical Profile – NST + AFI

VACCINATIONS

Tetanus Toxoid - 02 doses Killed/Inactivated/Toxoids can be given . Live vaccines are contraindicated

Not Given - BCG, Cholera, Japanese Encephalitis, Measles , Mumps, Rubella, Typhoid, Varicella

Give only if essential as safety in pregnancy has not been documented - Hepatitis A & E

Influenza Meningococcal OPV Rabies Diphtheria Yellow fever

MANAGEMENT OF COMMON SYMPTOMS IN PREGNANCY

NAUSEA & VOMITTING

More in primigravidas & multiple pregnancies

Cause - First/Increased exposure to HCG

No harm to fetus - Generally settles by 16-20wks

Diet - Avoid oily & spicy food

Small frequent meals

Home remedies – Ginger & lemon

Medications - T. Pyridoxine - twice daily

Severe cases – Inj. Metoclopramide

HEARTBURN

Effect of progesterone - reduced tone of lower esophageal sphincter

Diet modifications – reduce spicy food & eat small and frequent meals at short intervals

Postural modifications – avoid bending & lying down immediately after meals

Medications–H2 receptor blockers - Ranitidine

Proton Pump Inhibitors - Omez ®

Antacids - Gelusil®

CONSTIPATION

Effect of Progesterone – Relaxes musculature reduces tone & motility of smooth muscles

Diet modification – High fibre diet

Plenty of water

More fruits & vegetables

Medications – Mild Laxatives–Lactulose

Herbolax ®

Liquid Paraffin

VAGINAL DISCHARGE Due to vascular congestion & increased activity

of cervical mucus secreting glands

No treatment required

Watch for – Change of colour

Foul Smell

Associated Pruritis

Painful or burning micturition

Above signs indicate infection in which case the same will have to be treated accordingly

BACKACHE Initially due to pelvic organ congestion & later

due to strained pelvic supports & exaggerated lumbar lordosis

Lifestyle – as active as possible

Support- Lower back when sitting

Abdominal bump when lying down

Non-pharmacological - Back massage

- Hot fomentation

Drugs - Unrelenting cases - Analgesics

- Balms/gels for LA

HAEMORRHOIDS & VARICOSE VEINS

Due to vascular congestion

Effect of Progesterone

No effective treatment in pregnancy

Avoid constipation

Diet advice – high fibre, plenty of water

Leg elevation & avoid prolonged periods of standing

Compression stockings

Medications – Laxatives, creams & Flavinoids

Hirudoid cream

INTERVENTIONS NOT ROUTINELY RECOMMENDED

Repeated maternal weighing.

Breast or pelvic examination.

Iron or vitamin A supplements.

Routine Doppler ultrasound in low-risk pregnancies.

Ultrasound estimation of fetal size for suspected LGA

Routine screening for preterm labour.

Routine screening for cardiac anomalies using NT.

Routine fetal-movement counting.

Routine auscultation of the fetal heart.

Routine antenatal electronic cardio-tocography.

Routine ultrasound scanning after 24 weeks

THANKS