DR. Mazin Daghestani

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Definition:

Embryo:

Fetus:

Gravidity

Parity

Abortion:

Immature infant:

Preterm/premature infant:

Term:

Post term

Date/Post date

Birth rate

Fertility rate

Neonatal period:

I, II & III

Perinatal period:

Perinatal mortality rate:

Maternal mortality rate:

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Sign & symptoms of PRESUMPTIVE /PROBABLE manifestations

Pregnancy test:

Biological

Immunological

Radioimmunoassay for HCG

Serum vs urine

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“”Antenatal care is the clinical assessment of mother and fetus during pregnancy, for the purpose of obtaining the best possible outcome for both the mother and the fetus”

The aims of antenatal care:

Assessment and management of maternal risk and symptoms

Assessment and management of fetal risk

Prenatal diagnosis and management of fetal abnormalities

Diagnosis and management of perinatal complications

Decision regarding timing and mode of delivery

Education regarding pregnancy and childbirth

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Frequency of antenatal visitsFrequency of antenatal visits 12 weeks –booking + viability uss 16 weeks-blood screening (MW) 18 weeks-dating &detailed uss 24 weeks- 28 weeks- FBS, auto ab 30 weeks 32 weeks- growth uss 34 weeks 36 weeks – 38 weeks 40 weeks 41 weeks -

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booking visit (first visit): The aim:

obtain a comprehensive history and physical examinationestablish the gestational ageidentify the maternal and foetal risk factors

History:A FULL obstetric history particularly:LMP (last menstrual period)EDD (estimated delivery date)Past obstetric, gynaecological, medical and surgical historyFamily historySocial history ( inquire about smoking, alcohol, drugs)Identify factors and categories which make patient high or low risk.

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Assessment of gestational age:

Nagel’s rule (EDD) :Subtract 3 months from the date of the last menstrual period and add

7 days( 14 days in Arabic months).If the cycle was longer than 28 days, the number of additional days

are added to the days used in the rule Do the opposite if the cycle is shorter

Biparietal diameter: accurate +/- 3 weeks ( useful between wks 7-12)Crown rump length: accurate +/- 1 week (useful between wks 7-12) Fundal height: correspond to gestational age in weeks

.

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Measurement Symphyseal Measurement Symphyseal Fundal heightFundal height

Evidence supports either palpation or S- F measurement at every AN visit to monitor fetal growth

measurement should start at the variable point (F) and continue to the fixed point (S)

SF measurement should be recorded in a consistent manner (therefore cms at RWH)

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Fetal Presentation and DescentFetal Presentation and Descent

Check presenting part beginning around 30 weeks

Descent of presenting part is important as term approaches

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Auscultation of fetal heartAuscultation of fetal heart

Listening to fetal heart is of no known clinical benefit, but may be of psychological benefit to mother (Consensus opinion)

Should be offered at each visit after about 20 weeks

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Routine BP measurementRoutine BP measurement

HT is defined when systolic BP is 140mmHg +/or DBP is 90 mmHg or there is an incremental rise of 30 systolic or 15 diastolic

Automated devices & ambulatory devices should not be used (Mercury devises seem best)

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Urinalysis by dipstick for Urinalysis by dipstick for proteinuria - evidenceproteinuria - evidence

high incidence of false +ve and - ve using dipsticks cf 24 hr urine collection

reliable in detecting highly variable elevations in protein in pre-eclampsia– Gribble et al AJOG 1995; 173: 214-7

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Urinalysis by dipstick forn Urinalysis by dipstick forn proteinuria - evidenceproteinuria - evidence

no statistical differences in rates of PAH, fetal distress, abruptio placentae, neonatal outcome in those with absent, mild or marked proteinuria by dipstick

US and Canadian Guidelines recommend screening for pre-eclampsia by BP measurement rather than dipstick

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Urinalysis by dipstick for Urinalysis by dipstick for proteinuria - guidelinesproteinuria - guidelines

Routine screening for proteinuria in low risk pregnant women not recommended IV

assessment hypertensive pregnancies requires estimation of total protein in 24-hr collection IV

If detect hypertension then use dipstick for testing proteinuria

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Routine weighing at A/N visits Routine weighing at A/N visits - evidence- evidence

weighing at every antenatal visit routine practice for many years

No conclusive evidence for weighing at each visit. Maternal weight not clinically useful screening tool for detection of IUGR, macrosomia or pre-eclampsia IV

Weighing at booking or other times may be indicated eg anaesthetic risk assessment (done BIV at RWH) or maternal weight concerns

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Initial recommended testsInitial recommended tests

FBE MCHC/MCV (Thal screen. Ferritin and Hb

electrophoresis if low) Blood group/Ab screen HIV (level 1 evidence) Hep B Syphilis (ideally prior 16 weeks) Rubella Abs

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Urine testing- either 2 step or MSU+dipstick PAP if due

Consider Hep C Ferritin Vit D levels - common in patients at RWH addit Thal screen dating US

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Hepatitis C screeningHepatitis C screening

Should be offered to all at increased risk – history of injecting drugs– partner who injected drugs– tattoo or piercing– been in prison– blood t/f later positive for Hep C– long-term dialysis or organ transplant before

7/92

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Prenatal testingPrenatal testing

Down screening Screening - : early US, 15-17 week MSST,

Early combined screening(first trimester MSST and early US)

diagnostic testing - CVS, amniocentesis

Other testing according to history eg for CF, Fragile X, Thalassaemia, Huntington's disease

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Prenatal screening for Down’s Prenatal screening for Down’s syndromesyndrome

All women should be offered screening irrespective of age III/IV

counselling given by appropriately trained staff and specific to age of each woman III/IV

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Down syndrome screeningDown syndrome screening

Screening should– include accurate dating by 1st T u/s IV– either by 2nd T biochem, or nuchal translucency

alone or combination III– notify result irrespective of risk in

understandable format II– if increased risk should be offered further

counselling and diagnostic testing within 72 hrs or ASAP IV

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Down’s syndrome screeningDown’s syndrome screening

Quality of counselling is of primary importance, non-directional, if chooses screening, should be single-step III

Nuchal translucency should be performed at 11-14 weeks by trained operators and risks derived in conjunction with gestation and maternal age IV

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Other recommended testsOther recommended tests

26 weeks (at hospital)– Gestational diabetes screening -– AB screen on all women

36 weeks– GBS screen– (Ab if RH -ve has been ceased)

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Screening for GDMScreening for GDM

In absence of high level evidence to either support or abandon screening reasonable to– not offer screening– selectively offer screening to all with risk

factors– offer screening to all

if screening do so between 24-28 weeksRWH screen all women at 26 weeks

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Prevention of Early Onset Prevention of Early Onset GBSGBS

Swabs should be taken between 35-37 weeks’ III

Intrapartum antibiotics recommended if– <37 weeks’– ruptured membranes >18 before delivery– maternal temperature 38 C– previous GBS colonisation, bacteruria or infant

with GBS III

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Antenatal anti-D prophylaxisAntenatal anti-D prophylaxis

Prophylactic Anti-D at 28 and 34 weeks’ gestation No level I evidence Level II and III evidence would suggest that the

1.5 percent immunisation rate could be reduced to 0.1-0.2% through antenatal prophylaxis (Huchet et al, 1987;Bowman and Pollock, 1978; Hermann et al, 1974)

www.health.gov.au/nhmrc/publications/pdf/wh27.pdf

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Investigation:routine test:

Blood group and Rh type ( if positive, appropriate management)CBCUrine analysis- to prevent UTI affecting pregnancy)MSUHBs Ag ( if a mother has it, 70-90% chance of foetus getting it, 90% chance of being chronic carrier. Prevent by treating newborn of HBs AG+ve mother with B immune globulin and hep B vaccine)RubellaSyphilisU/S:

Determine foetal crown rump length and thus gestational ageIdentify multiple gestationIdentify gross abnormalities/ markers of genetic disease.

Cervical cytology

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2-Screening tests:AnaemiaGestational DM (best carried out between 24 and 28 weeks, observe 1 hr after 50g glucose solution. A reading of 126 mg/dl or greater is abnormal, according to the amended WHO recommendations 1999 regarding DM, as is HbAlc of greater than 90%. In these cases proceed to glucose tolerance test)AntibodiesTriple test: Alpha feto protein in normal serum, oestriol, HGG ( to detect neural tube defect or chromosomal defect, 16-18 weeks)Hb electrophoresisTuberculin skin testingUrine culture- for glucose, ketones and protein, bacilliCervical culture: N gonorrhoea, group B streptococci, Chlamydia trachomatis, Mycoplasma hominisToxoplasma antibody testHIV

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HIV: Voluntary Counseling HIV: Voluntary Counseling and Testingand Testing

Voluntary HIV counseling and testing should be available to every pregnant woman--for public health reasons as well as for the benefit to the individual woman.

Pre and post-test counseling is an essential part of managing HIV in pregnancy.

Source: WHO and UNAIDS 1999.

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Benefits of Voluntary HIV Benefits of Voluntary HIV Counseling and TestingCounseling and Testing

1)If the HIV test is positive, the woman can get early counseling and treatment

2)Allows appropriate follow-up and treatment of child

3)Enables a woman to make decisions regarding continuation of the pregnancy and future fertility

4)May allow the institution of anti-retroviral (ARV) therapy

Source: WHO and UNAIDS 1999.

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Benefits of Voluntary HIV Benefits of Voluntary HIV Counseling and Testing Counseling and Testing

continuedcontinued5) Provides the opportunity to implement strategies that attempt to prevent transmission to the child

6) Can inform partner and enable him to get counseling and testing

7) Women can take precautions to prevent transmission to partners

8) If the HIV test is negative, the woman can be guided in appropriate HIV prevention

Source: WHO and UNAIDS 1999.

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SyphilisSyphilis

Maternal-fetal transmission may be as high as 80%.

Incidence of adverse effects on the fetus/infant due to untreated maternal syphilis reported in some studies was:– Spontaneous abortion – 20%– Perinatal death – 30%– Congenital syphilis – 25%

Source: WHO 1991.

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Syphilis Syphilis continuedcontinued

A study in Zambia found syphilis to be the single most common cause of fetal wastage. The adverse outcomes of syphilis were halved by a fairly incomplete program of screening and treatment.

Sources: Hira et al 1990; Tinker and Koblinsky 1993.

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Syphilis Syphilis continuedcontinued

Even where prevalance is relatively low (i.e., as in most industrialized countries) an antenatal syphilis screening program is a cost-effective intervention.

Initiation of treatment should occur at the same visit as the screening.

Source: Wang and Smaill 1989.

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TuberculosisTuberculosis

Infants born to women with tuberculosis (TB) have an increased risk of morbidity and mortality in the neonatal period.

Source: Figueroa-Damian and Arredondo-Garcia 2001.

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Severe anemiaSevere anemia

Mild or moderate anemia is not correlated with adverse pregnancy outcomes

Severe anemia, however, (hgb <7 g/dL or hct <20%) is associated with increased preterm delivery, inadequate intrauterine growth, increased perinatal mortality and increased maternal mortality.

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Severe anemia Severe anemia continuedcontinued

Providers can screen for anemia by

1)Hemoglobin (hgb) by thin film/smear

2)Hematocrat (hct) test

3)Hemoglobin Color Scale, or

4)Clinical observation of the inferior conjunctiva of the eye, the nail beds and the palm. If any of these are pale, the woman is severely anemic.

Other symptoms include shortness of breath and signs of heart failure.

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Tetanus ToxoidTetanus Toxoid

Tetanus toxoid is– An effective, stable, cheap toxoid which has been

available for > 50 years and is produced in many developing countries.

– Effective in preventing neonatal tetanus (NNT), which causes approximately half a million deaths/year) and maternal tetanus, which is estimated to cause 30,000 deaths annually.

Sources: Fauveau V et al 1993; Bennett JV 2000.

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Iron DeficiencyIron Deficiency

Globally among all populations, iron deficiency (and its manifestation in anemia) is the single most prevalent nutrient deficiency condition. The World Health Organization (WHO) estimates put anemia prevalence at 52% among pregnant women.

Source: MotherCare, John Snow, Inc. 2000.

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Iron Folate SupplementsIron Folate Supplements The International Nutritional Anemia Consultative

Group, WHO and UNICEF have endorsed the following guidelines:1) All women should consume daily iron folate

supplements for 6 months during pregnancy.2) Where anemia prevalence is <40%, women should

receive supplements of 60 mg iron and 400 micrograms of folate

3) In areas where anemia prevalence is high among pregnant women (40%), women should continue the same dosage for 3 months into postpartum.

Sources: Stoltzfus and Dreyfuss 1998; McDonagh 1996.

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3-Specific nutritional advice: 0.4 mg Folic Acid per day ( it prevents tube defects)30 mg ferrous iron60 mg ferrous iron 2 times a day ( anaemic patients)Supplement copper and zinc in anaemic patientsAvoid Vitamin A in huge amounts as it is teratogenic

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Nutrition RequirementsNutrition Requirements

Good antenatal nutrition includes:Meeting the caloric needs Eating foods which supply specific

micronutrients Providing micronutrient supplementation

An underweight mother increases the likelihood of a low birth weight (LBW) baby; low iron intake contributes to anemia.

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Models of antenatal careModels of antenatal care

At each visit midwives and doctors should offer information, consistent advice, clear explanations and provide opportunity to ask questions III/IV

More likely to be satisfied with A/N care when perceive care givers are kind, supportive, courteous, respectful, recognise individual needs IV

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Complications Cannot Be Complications Cannot Be Reliably PredictedReliably Predicted

No formula or scoring system can reliably distinguish those who will develop complications from those who will not.

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Complication Readiness is Key Complication Readiness is Key to Survivalto SurvivalNepal Study

Less than 50% of families of women who died in pregnancy, delivery or postpartum, recognized the problem.

36% decided within 2 hours to seek care and get transport. 15% decided in 2 to 23 hours to seek care and get transport. 29% made the decision and arranged transport 1 to 8

or more days after recognition of a life-threatening complication.

Source: MOH, Nepal 1998.

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Complication Readiness is Key Complication Readiness is Key to Survival to Survival continuedcontinued

The interval from onset to death for antepartum hemorrhage can be approximately 12 hours.

The interval from onset to death for postpartum hemorrhage can be two hours.

The hours required for making arrangements (which could have been made prior to the emergency) may define the line between survival and mortality.

Sources: Maine 1991; MOH, Nepal 1998.

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Danger SignalsDanger SignalsFamilies of pregnant women need to know

how to recognize the signs of complications as well as what to do and where to get help

In Nepal, less than 50% of families of women who died recognized the problem.

Source: MOH, Nepal 1998.

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On subsequent visits

Check:

oBp 0 urine analysis 0 weight?

Ask for :

0 FM 0 Maternal complaints

Examine:

0 abdomen/obstetric 0 listen/see FH USS if required

Advice:

Treatment of complaint & health education

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1. Infections:

SyphilisHepatitisH.I.V.

Rubella

2 .Blood disorders:

Sickle cell

Thalassaemia

3 .Fetal anomalies:

Structural e.g. N.T.D

4 .Chromosomal abnormalities:

Down’s

T18

T13

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Non Invasive: B-HCG …. Urine 14 days post ovulation, serum 7-9 days ….. doubling time….. Alpha feto protein. Triple test: AFP, Unconjugated oestriol & B-HCG Ultra Sound scan

Invasive: Amniocentesis

Chorionic villus biopsy

Chordocentesis

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Indications of use:

pregnancy location

viability

fetal number

dating

anomaly

placental localization, amniotic fluid

fetal growth and wellbeing

during invasive procedures

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Amniocentesis:

carried at 15-18 wks. Failure rate < 1%.. Culture time 10-12 days

For chromosomal analysis: Down’s etc…

Miscarriage rate 0.5-1%.... Experience and USS

Anti-D

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Fetal blood sampling:

Ultra sound guided. Cord insertion into the placenta

Only in specialist centres

indications:

Rh iso-immunisation

non-immune hydrops

Fetal infection

Rapid karyotyping in some IUGR

Anti-D

Fetal loss ~ 1%.

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Assessment of gestational age and fetal growth:

menstrual history unreliable in up to 45% of women

serial fundal height measurement provides a guide to fetal growth

USS: crown-rump length before 14 weeks

USS: BPD serial measurement every 2 weeks for fetal growth. Unreliable after 28 weeks for dating

USS: head/abd ratio, 2 weeks serial HC & AC for fetal growth .. IUGR AC< but initially HC ~.

USS: femur length, more precise guide to gestational age than BPD

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Principles:

the ideal scheme to assess FWB should:

Take account of cycles of normal fetal behavior

detect impending harm accurately and in time to intervene to prevent it

give reassurance preferably up to 7 days

avoid causing unnecessary anxiety

allow detection of specific causes e.g hypoxia, infection, malf’n

produce measurable benefits in reducing perinatal loss/injury

such system is likely to involve tests which assess several fetal systems, CVS, NS,, RS and use >1 modality

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Fetal Movement Count:

Fetal Heart Recording….. CTG

Biophysical Profile {BPP} scoring

Doppler studies

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BPP uses FHR monitor and real time USS to assess:

fetal breathing movement

discrete body or limb movement

fetal tone

FHR

amniotic fluid volume

Amniotic fluid volume is most important

Fetal breathing movement is the first to disappear in asphyxia

7 days reassurance in low risk, only 24 hours in high risk preg

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Clinical Indications for Doppler Studies

most useful in assessing IUGR

identify only the sub-group which is hypoxemic bec/of inadequate placental function and may be abnormal for up to 18 weeks before any fetal problem is observed

no proven role in population screening for increased risk of pre-eclampsia or IUGR

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